Chapter 8

Disorders of Neurovegetative
Function: Feeding, Eating and Sleep-
Wake Disorders
 Feeding and Eating Disorders

▪ In this chapter we talk about the psychological

disruptions of two neurovegetative functions:
eating and sleeping, which substantially affect the
rest of our behaviour.
▪ DSM-5 recognizes three feeding
and three eating disorders: pica,
rumination disorder, avoidant
restrictive food intake disorder,
anorexia nervosa, bulimia nervosa and binge-
eating disorder.
 Scope and Severity of Eating Disorders

▪ Have you heard of a pregnant women

craving gherkins, chutney, potato
chips?
▪ It is not uncommon for people
deficient in one or another nutrient to crave strange
foods and even to eat non-foodstuff such as sand
and clay. This behavior is known as pica.
▪ Pica is characterized by persistently eating one or
more non-nutritive, non-food substances for at
least a month.
▪ Non-food materials ingested in pica
include ice, starch, clay, chalk, paint,
paper, soap, string, soil, feces and hair.
 Scope and Severity of Eating Disorders

▪ The prevalence of pica is not known but both

females and males are affected.
▪ Most commonly it emerges in
childhood, but it can appear at
any time.
▪ Chronically, pica represents a
serious, potentially lethal, health risk with
nutritional deficiencies, poisoning, infections and
intestinal obstruction.
▪ Rumination disorder is characterized by repeated
regurgitation of food after feeding or eating.
▪ To ruminate literally means to chew cud, as is the
practice with cattle.
 Scope and Severity of Eating Disorders

▪ Without apparent retching, nausea or disgust at the

practice, a person with rumination
disorder brings up previously
swallowed food – often partially
digested – into the oral cavity to
re-chew.
▪ Sometimes, this partially digested material may be
ejected from the mouth.
▪ The behavior seems to be more common in people
with mental retardation, although a degree of
rumination is not unusual in infants (between 3 and
12 months).
▪ Malnutrition is a common complication.
 Scope and Severity of Eating Disorders

▪ Avoidant/restrictive food intake disorder is a

replacement and extension of the DSM-IV feeding
disorder of infancy and childhood.
▪ The avoidance of food and restriction of its intake
characterise this disorder.
▪ Some children appear particularly averse to certain
sensory qualities of foods – appearance, smell and
texture as well as taste.
▪ Infants become agitated when
fed and might not engage in
feeding-related behaviours.
 Scope and Severity of Eating Disorders

▪ Infants may appear apathetic or irritable and

difficult to console during feeding.
▪ Weight loss, failure to thrive, nutritional
deficiencies and, later, dependence on nutritional
supplementation are its consequences.
 Scope and Severity of Eating Disorders

Major Types of Eating Disorders:

▪ Bulimia Nervosa, out-of-control eating
episodes, or binges, are followed by
self-induced vomiting, excessive use of
laxatives, or other attempts to purge
(get rid of) the food.
▪ In Anorexia Nervosa, the person eats
nothing beyond minimal amounts of
food, so body weight sometimes drops
dangerously; it is also tightly coupled to
an extremely distorted body image.
 Scope and Severity of Eating Disorders

▪ In Binge-eating Disorder, individuals

may binge repeatedly and find it
distressing even, but they do not
attempt to purge the food.
▪ The chief characteristic of these
related disorders is an overwhelming, all-
encompassing drive to be thin.
▪ Of the people with anorexia nervosa, up to 20% die
as a result of their disorder, with slightly more than 5%
dying within 10 years.
▪ Anorexia nervosa has the highest mortality rate
of any psychological disorder reviewed in this
book, including depression.
 Scope and Severity of Eating Disorders

▪ From 20% to 30% of anorexia-related

deaths are suicides.
▪ A growing number of studies in
different countries indicate that eating
disorders are widespread and
increased dramatically in Western countries from
about 1960 to 1995, before seeming to level off
somewhat.
▪ What makes eating disorders even more intriguing is
that they tend to be culturally specific.
▪ Until recently, eating disorders, particularly bulimia,
were not found in developing countries, where
access to sufficient food is so often a daily struggle.
 Scope and Severity of Eating Disorders

▪ Only in the West, where food was generally plentiful,

have they been rampant.
▪ Now this has changed; evidence suggests that eating
disorders are going global.
▪ More than 90% of the severe cases are young
females who live in a socially competitive
environment.
▪ In these disorders, unlike most others, the strongest
contributions to aetiology seem to be sociocultural
rather than psychological or biological factors.
 Anorexia Nervosa
Anorexia Nervosa: Clinical Description
▪ Individuals with anorexia nervosa (which literally
means a “nervous loss of appetite”—an incorrect
definition because appetite often remains healthy)
differ in one important way from individuals with
bulimia.
▪ They are so successful at losing
weight that they put their lives in
considerable danger.
▪ Both anorexia and bulimia are characterized by a
morbid fear of gaining weight and losing control
over eating.
 Anorexia Nervosa
▪ The major difference seems to be whether the
individual is successful at losing weight.
▪ People with anorexia are proud of both their diets and
their extraordinary control.
▪ Although decreased body weight is the most
notable feature of anorexia nervosa, it is not the
core of the disorder.
▪ People with anorexia have an intense fear of obesity
and relentlessly pursue thinness.
▪ It often begins with dieting that escalates into an
obsessive preoccupation with being thin. Severe,
almost punishing exercise is common.
 Anorexia Nervosa
▪ Dramatic weight loss is achieved
through severe caloric restriction
or by combining caloric restriction
and purging.
▪ 15% below expected weight
(the average is approximately 25% to 30% below
normal by the time treatment is sough).
▪ DSM-5 specifies two subtypes of anorexia nervosa:
▪ In the restricting type, individuals diet to limit calorie
intake.
▪ In the binge-eating–purging type, they rely on
purging.
 Anorexia Nervosa

▪ Unlike individuals with bulimia, binge-eating–

purging anorexics binge on relatively small
amounts of food and purge more consistently, in
some cases each time they eat.
▪ Individuals with anorexia are never
satisfied with their weight loss.
▪ Staying the same weight from one
day to the next or gaining any
weight is likely to cause intense
panic, anxiety and depression.
 Anorexia Nervosa
▪ Only continued weight loss every day for weeks on
end is satisfactory.
▪ Another key criterion of anorexia is a
marked disturbance in body image.
▪ Individuals with anorexia seldom seek
treatment on their own.
▪ Usually, pressure from somebody in the
family leads to the initial visit.
▪ Perhaps as a demonstration of absolute control
over their eating, some individuals with anorexia
show increased interest in cooking and food.
▪ Others hoard food in their rooms, looking at it
occasionally.
Anorexia
Nervosa
 Anorexia Nervosa
Medical Consequences
▪ One common medical complication of anorexia
nervosa is cessation of menstruation (amenorrhea)
▪ Dry skin
▪ Brittle hair and nails
▪ Sensitivity to or intolerance of cold temperatures
▪ Lanugo (downy hair on
the limbs and cheeks)
▪ Cardiovascular problems
such as chronically low blood pressure and heart
rate
 Anorexia Nervosa

▪ Electrolyte imbalance
▪ Cardiac and kidney problems
Associated Psychological Disorders
▪ Anxiety disorders and mood
disorders are often present in
individuals with anorexia, with
rates of depression occurring at
some point during their lives in
as many as 71% of cases.
▪ Interestingly, one anxiety disorder that seems to co-
occur often with anorexia is obsessive-compulsive
disorder (OCD).
 Anorexia Nervosa
▪ In anorexia, unpleasant thoughts
are focused on gaining weight
and individuals engage in a variety
of behaviours, some of them
ritualistic, to rid themselves of
such thoughts.
▪ Substance abuse is also common in individuals with
anorexia nervosa and, in conjunction with anorexia, is
a strong predictor of mortality, particularly by
suicide.
 Bulimia Nervosa
Bulimia Nervosa
▪ The hallmark of bulimia nervosa
is eating a larger amount of food,
typically easily palatable, high-
energy containing foods, than most
people would eat under similar circumstances.
▪ Just as important as the amount of food
eaten is that the eating is experienced as
out of control.
▪ Another important criterion is that the
individual attempts to compensate for the
binge eating and potential weight gain,
almost always by purging techniques.
 Bulimia Nervosa

▪ Techniques include self-induced vomiting

immediately after eating and using laxatives (drugs
that relieve constipation) and diuretics (drugs that
result in loss of fluids through greatly increased
frequency of urination).
▪ Some people use both methods; others attempt to
compensate in other ways.
▪ Some exercise excessively (although rigorous
exercising is more usually a characteristic of anorexia
nervosa).
▪ Others fast for long periods between binges.
 Bulimia Nervosa
▪ Bulimia nervosa was subtyped in
DSM-IV-TR into purging type
(e.g., vomiting, laxatives, or diuretics)
or non-purging type (e.g., exercise
and/or fasting).
▪ But the non-purging type has turned out to be quite
rare, accounting for only 6% to 8% of patients with
bulimia.
▪ Furthermore, these studies found little evidence of any
differences between purging and non-purging types of
bulimia. As a result, this distinction was dropped in
DSM-5.
 Bulimia Nervosa

▪ They feel that their popularity and

self-esteem will largely be determined
by the weight and shape of their
bodies.
▪ Most are within 10% of normal weight.
Bulimia
Nervosa
 Bulimia Nervosa

Medical Consequences
▪ Electrolyte and other metabolic abnormalities may
be life-threatening and include hyponatraemia ( too
low sodium concentration) with delirium and
seizures.
▪ Hypokalaemia (too low potassium concentration) that
can lead to cardiac arrhythmias (irregular heartbeats).
▪ Hypocalcaemia (too low calcium concentration) with
cramps, spasm, cardiac problems, panic, confusion
and seizures.
▪ Hypomagnesaemia.
 Bulimia Nervosa

▪ Excessive diuresis, or induced urination, may cause

dehydration and further electrolyte problems.
▪ Prolonged laxative use may also lead to so-called
paralytic ileus – or actual paralysis of the bowel,
with no movements.
▪ Amenorrhea also occurs relatively often in bulimia.
▪ Local complications or damage to tissue include
erosion of dental enamel, dental
caries, tooth loss and enlarged
parotid glands – the salivary glands
right before the ears (gives the face a
chubby appearance).
 Bulimia Nervosa
▪ Tearing of the oesophagus may
occur during vomiting.
▪ Gastric dilatation may occur,
particularly during swift re-feeding.
▪ Callosities on the fingers also
develop because of repeated friction of the fingers
against the teeth and throat when inducing vomiting.
▪ Surprisingly, young women with bulimia also develop
more body fat than age- and weight-matched healthy
controls, the very effect they are trying to avoid.
 Bulimia Nervosa

Associated Psychological Disorders

▪ Depressive, bipolar, anxiety and personality
disorders are commonly associated with bulimia
nervosa.
▪ Up to 80% of bulimia patients experience an anxiety
disorder at some point during their lives.
▪ Depression also commonly
co-occurs with bulimia, with about
20% of bulimic patients meeting
criteria for a mood disorder when
interviewed and between 50% and
70% meeting criteria at some point during the course
of their disorder.
 Bulimia Nervosa

▪ Finally, substance-use disorders commonly

accompany bulimia nervosa.
▪ It was reported that 36.8% of individuals with bulimia
and 27% of individuals with anorexia were also
abusing substances.
▪ Shared risk factors of novelty seeking and emotional
instability accounted for the high rates of
comorbidity between bulimia and anxiety and
substance use disorder.
 Binge-Eating Disorder
▪ Binge-Eating Disorder
▪ These individuals experience marked
distress because of binge eating
but DO NOT engage in extreme
compensatory behaviors and
therefore cannot be diagnosed with bulimia.
▪ Binge-Eating Disorder is now recognized as an
eating disorder in DSM-5.
▪ Individuals who meet preliminary criteria for BED are
often found in weight-control programs. Of mildly
obese participants in a weight-control program studied,
18.8% met criteria for BED. In other programs, with
participants ranging in degree of obesity, close to 30%
met criteria.
 Binge-Eating Disorder

▪ The general consensus is that about

20% of obese individuals in weight-
loss programs engage in binge
eating, with the number rising to
approximately 50% among
candidates for bariatric surgery (surgery to correct
severe or morbid obesity).
▪ About half of individuals with BED try dieting before
bingeing, and half start with bingeing and then
attempt to diet.
▪ Those who begin bingeing first become more
severely affected by BED and are more likely to
have additional disorders.
 Binge-Eating Disorder
▪ It’s also increasingly clear that individuals with BED
have some of the same concerns about shape and
weight as people with anorexia and bulimia, which
distinguishes them from individuals who are obese
without BED.
▪ It also seems that approximately
33% of those with BED binge to
alleviate “bad moods” or
negative affect.
▪ These individuals are more psychologically
disturbed than the 67% who do not use bingeing to
regulate mood.
▪ They show a better response to treatment.
Binge-Eating
Disorder
 Epidemiology of Eating Disorders

▪ Among those who present for treatment, the

overwhelming majority (90% to 95%) of individuals
with bulimia are women.
▪ Males with bulimia have a slightly later
age of onset, and a significant minority
is gay or bisexual.
▪ Male athletes in sports that require
weight regulation, such as wrestling,
are another large group of males with
eating disorders.
▪ More recent studies suggest the incidence among
males is increasing.
 Epidemiology of Eating Disorders

▪ Among women, adolescent girls are most at risk. A

recent prospective 8-year survey of 496 adolescent
girls reported that more than 12% experienced some
form of eating disorder by the time they were 20.
▪ Eating-related problems of 1,498 freshmen women at a
large university were studied over the 4-year college
experience.
▪ Only 28% to 34% had no eating-related concerns.
But 29% to 34% consistently attempted to limit their
food intake because of weight/shape concerns; 14%
to 18% engaged in overeating and binge eating;
another 14% to 17% combined attempts to limit
intake with binge eating; and 6% to 7% had
pervasive bulimic-like concerns.
 Epidemiology of Eating Disorders

▪ A large study in Finland based on a telephone survey

found a lifetime prevalence of anorexia of 2.2%.
▪ The median age of onset for all
eating-related disorders
occurred in a narrow range of
18 to 21 years.
▪ Once bulimia develops, it tends to be chronic if
untreated.
▪ Once anorexia develops, its course seems chronic
— although not so chronic as bulimia, particularly if it
is identified early and treated.
Epidemiology of Eating Disorders
 Brief Notes on Obesity

▪ Although Obesity cannot be

considered a mental disorder, it is
mentioned because it is a serious
public health concern.
▪ Obesity in the modern world, across developed and
developing societies is a primary factor in a range of
serious afflictions, from hypertension, to arterial
disease and even dementia.
▪ These risks are widespread and involve greatly
increased prevalence of cardiovascular disease,
diabetes, hypertension, stroke, gallbladder disease,
respiratory disease, muscular skeletal problems,
and hormone-related cancers.
 Brief Notes on Obesity

▪ The latest surveys indicate that nearly 70% of U.S.

adults are overweight and more than 35% meet
the criteria for obesity.
▪ South Africa has the highest rate of
obesity in sub-Saharan Africa, with
nearly two-thirds of adult women
overweight and 40% obese; one-
third of adult men classifiable as
obese.
▪ The prevalence rates of obesity has also
demonstrated a secular increasing trend.
▪ There are two forms of maladaptive eating patterns
in people who are obese.
 Brief Notes on Obesity

▪ The first is binge-eating and the second is night

eating syndrome. Only a minority of patients with
obesity, between 7% and 19% present with patterns
of binge-eating.
▪ More interesting is the pattern of
night eating syndrome that occurs
in-between 6% and 16% of obese
persons seeking weight-loss
treatment but in as many as 55% of those with
extreme obesity seeking bariatric surgery.
▪ Individuals with night-eating syndrome consume a
third or more of their daily intake after their evening
meal and get out of bed at least once during the night
to have a high-calorie snack.
 Brief Notes on Obesity

▪ In the morning, however, they are not hungry and

usually do not eat breakfast.
▪ These individuals do not binge during their night
eating and seldom purge.
▪ There is a relationship of night eating syndrome with
increasing levels of obesity.
▪ This condition is not the same as the nocturnal
eating syndrome described later in the section on
sleep disorders.
▪ In that condition, individuals get up during the night
and raid the refrigerator but never wake up.
 Brief Notes on Obesity

▪ They may also eat uncooked or other dangerous

foods while asleep.
▪ On the contrary, in night eating syndrome, the
individuals are awake as they go about their nightly
eating patterns.
 Sleep–Wake Disorders

Preliminary Considerations
▪ Patients with sleep-wake disorders typically complain
about the amount of time spent
sleeping, the timing of sleep
and poor quality of sleep, all of
which cause daytime distress
and impairment.
▪ The diagnosis of sleep-wake disorders requires a
multidimensional approach.
▪ Sleep disturbances commonly accompany
depression, anxiety and cognitive disorders.
 Sleep–Wake Disorders

▪ We spend about one third of our lives sleeping,

but unfortunately, most people do not get enough
sleep, and 28% of people in the United States
report feeling excessively sleepy during the day.
▪ In Brazil, poor sleep affects more than 70% of the
adult population.
▪ South Africa is not far behind with more than 40%
prevalence of poor sleep.
Our Evolving Understanding of Sleep-Wake Disorders
▪ The study of sleep has long influenced concepts of
abnormal psychology.
 Sleep–Wake Disorders

▪ DSM-5 considers sleep-wake disorders across five

major categories: dyssomnias, narcolepsy,
breathing-related sleep disorders, circadian rhythm
sleep disorders and parasomnias.
▪ Dyssomnias involve the amount, timing and quality of
sleep; narcolepsy is a circumscribed neuropsychiatric
condition with fairly well elucidated aetiology;
breathing related disorders concern problems with
ventilation associated with disturbed sleep architecture;
circadian rhythm disorders consider disturbances in
circadian functions and includes shift work and jet lag;
 Sleep–Wake Disorders

▪ Parasomnias are abnormal, often distressing events

that occur during various stages of sleep
and include nightmares, night terrors,
sleepwalking and breathing-related
problems.
Sleep–Wake Disorders
 Insomnia Disorder

▪ Insomnia is one of the most

common complaints in general
practice.
▪ A simple aid to understand the
concept of insomnia is the acronym DIMS – Disorders
of Initiation and Maintenance of Sleep.
▪ Insomnia comprises initial, middle and terminal
insomnia as well as non-restorative sleep.
▪ Initial = If they have trouble falling asleep at night
(difficulty initiating sleep).
▪ Middle = If they wake up frequently during the night
and struggle to go back to sleep (difficulty
maintaining sleep).
 Insomnia Disorder

▪ Terminal = If they wake up too

early and can’t go back to sleep.
▪ Non-restorative sleep occurs
where, despite sleeping for
adequate duration, patients continue to feel
unrefreshed or unrested upon awakening.
Clinical description
▪ When sleep problems are not related to other medical
or psychiatric problems, the DSM-5 criteria for
insomnia disorder are met. This is called primary
insomnia.
 Insomnia Disorder

▪ Insomnia’s impact is all too prominent during

wakefulness.
▪ Although many people can carry out necessary day-
to-day activities, their inability to
concentrate can have serious
consequences – driving suffers,
it becomes dangerous to use
power tools, and academic
performance and other intellectual tasks suffer.
▪ Patients with insomnia may complain of depression,
irritability, ecxessive emotionality, a tendency to
catastrophise problems, procrastination and a lack
of self-confidence.
 Insomnia Disorder

▪ They worry about sleep.

▪ They may look fatigued, yawn
during consultations or become
fidgety.
Insomnia Disorder
 Insomnia Disorder

Epidemiology
▪ In the USA, almost a third (33%)
of the population reports some
symptoms of insomnia during
any given year.
▪ For many of these individulals, sleep difficulties are a
lifetime affliction.
▪ In South Africa, insomnia disorder or primary
insomnia where an underlying coexisting condition
is not to blame, appears to have a prevalence of 10%.
▪ Women report insomnia twice as often as men.
 Insomnia Disorder

▪ Just as people’s needs concerning normal sleep

change over time, complaints of insomnia differ in
frequency among people of different ages.
▪ Children who have difficulty falling asleep usually
throw a tantrum at bedtime or do not want to go to
bed.
▪ Estimates of insomnia among young children range
from 20% to more than 40%.
▪ As children move into adolescence, their sleep
schedules shift toward a later bedtime.
 Insomnia Disorder

▪ Complaints of poor sleep increase with age up to

late middle age.
▪ In the elderly there is a slight tail-off in complaints,
although sleep duration decreases substantially.
▪ Insomnia disorder is frequently associated with:
▪ Anxiety
▪ Depression
▪ Substance use disorder
▪ Dementia of the Alzheimer’s
type
 Hypersomnolence Disorders

Hypersomnolence Disorders
▪ Insomnia disorder involves not getting enough
sleep (the prefix in means “lacking” or “without”), and
hypersomnolence disorders
involve sleeping too much
(hyper means “in great amount”
or “abnormal excess”).
▪ Many people who sleep all night
find themselves falling asleep several times the next
day.
▪ The DSM-5 diagnostic criteria for hypersomnolence
include not only the excessive sleepiness but also
the subjective impression of this problem.
 Hypersomnolence Disorders

▪ Several factors that can cause excessive sleepiness

would not be considered hypersomnolence.
▪ For example, people with insomnia disorder (who get
inadequate amounts of sleep) often report being
tired during the day.
▪ In contrast, people with hypersomnolence sleep
through the night and appear
rested upon awakening but still
complain of being excessively tired
throughout the day.
▪ Another sleep problem that can cause a similar
excessive sleepiness is a breathing-related sleep
disorder called sleep apnea.
 Hypersomnolence Disorders

▪ People with this problem have difficulty breathing at

night.
▪ They often snore loudly, pause between breaths,
and wake in the morning with a dry mouth and
headache.
▪ In identifying hypersomnolence, the clinician needs
to rule out insomnia, sleep apnea, or other reasons
for sleepiness during the day.
Hypersomnolence
Disorders
 Narcolepsy

Narcolepsy
▪ Narcolepsy is a curious, but
surprisingly common, neurological
condition.
▪ It is defined by sleep attacks where
the person has an overwhelming urge to sleep.
▪ They may also experience sleep paralysis and
vivid hallucinations, typically while falling asleep
or awakening.
▪ These hallucinations are respectively known as
hypnagogic and hypnopompic hallucinations.
Interestingly, hypnopompic hallucinations are
common experiences in normal people.
 Narcolepsy

▪ Often patients also suffer from cataplexy, a sudden

loss of muscle tone.
▪ Cataplexy occurs while the person is awake and can
range from slight weakness in the facial muscles to
complete physical collapse.
▪ Cataplexy lasts from several seconds to several
minutes; it is usually preceded by strong emotion
such as anger or happiness.
▪ Cataplexy appears to result from a sudden onset of
REM sleep.
 Narcolepsy

▪ Instead of falling asleep normally and going

through the four non-rapid eye movement (NREM)
stages that typically precede REM sleep, people with
narcolepsy periodically progress right to this dream-
sleep stage almost directly from the state of being
awake.
▪ One outcome of REM sleep is the inhibition of input
to the muscles, a functional disruption of motor
output that occurs in the pons of the brainstem.
▪ Two other characteristics distinguish people who
have narcolepsy.
 Narcolepsy

▪ They commonly report sleep

paralysis, a brief period after
awakening when they cannot
move or speak that is often
frightening to those who go through it.
▪ The last characteristic of narcolepsy is
hallucinations in sleep transience – hypnagogic
and hypnopompic hallucinations.
▪ These hallucinatory phenomena are vivid and
frequently terrifying experiences and are said to be
unbelievably realistic because they include not only
visual aspects but also touch, hearing and even
sensation of body movement.
 Narcolepsy

▪ Narcolepsy is relatively rare, occurring in .03% to

.16% of the population, with the number approximately
equal between males and females.
▪ Although some cases have been reported in young
children, the problems associated with narcolepsy
are usually first seen during the teenage years.
▪ Excessive sleepiness usually occurs first, with
cataplexy appearing either at the same time or with
a delay of up to 30 years.
▪ Fortunately, the cataplexy, hypnogogic
hallucinations and sleep paralysis often
decrease in frequency over time, although
sleepiness during the day does not seem
to diminish with age.
 Narcolepsy

▪ Sleep paralysis and hypnagogic

hallucinations may serve a role in
explaining a certain phenomenon –
unidentified flying object (UFO)
experiences.
Narcolepsy
 Breathing-Related Sleep Disorders

Breathing-related Sleep Disorders

▪ For some people, sleepiness during the day or
disrupted sleep at night has a physical origin—
namely, problems with breathing
while asleep.
▪ In DSM-5, these problems are
diagnosed as breathing-related
sleep disorders.
▪ People whose breathing is interrupted during their
sleep often experience numerous brief arousals
throughout the night and do not feel rested even after
8 or 9 hours of sleep.
 Breathing-Related Sleep Disorders

▪ For all of us, the muscles in the upper airway

relax during sleep, constricting the passageway
somewhat and making breathing a little more
difficult.
▪ For some, unfortunately, breathing is constricted a
great deal and may be laboured (hypoventilation)
or, in the extreme,
there may be short
periods (10 to 30
seconds) when they
stop breathing
altogether, called
sleep apnea.
 Breathing-Related Sleep Disorders

▪ Often the affected person is only minimally aware of

breathing difficulties and doesn’t attribute the sleep
problems to the breathing.
▪ A bed partner usually notices
loud snoring (which is one sign
of this problem), however, or will
have noticed frightening
episodes of interrupted breathing.
▪ Other signs that a person has breathing difficulties
are heavy sweating during the night, morning
headaches, and episodes of falling asleep during the
day (sleep attacks) with no resulting feeling of being
rested.
 Breathing-Related Sleep Disorders

▪ There are three types of apnoea, each with different

causes, daytime complaints, and treatment:
obstructive, central, and mixed sleep apnoea.
▪ Obstructive sleep apnoea hypopnea syndrome
occurs when airflow stops despite continued activity
by the respiratory system.
▪ In some people, the airway is too narrow; in others,
some abnormality or damage interferes with the
ongoing effort to breathe.
▪ Everyone in a group of people
with obstructive sleep apnoea
hypopnea syndrome reported
snoring at night.
 Breathing-Related Sleep Disorders

▪ Obesity is sometimes associated

with this problem, as is increasing
age.
▪ Some work now suggests that the
use of MDMA (ecstasy) can lead
to obstructive apnoea hypopnea syndrome even in
young and otherwise healthy adults.
▪ Obstructive sleep apnoea is most common in males
and is thought to occur in 10% to 20% of the
population.
 Breathing-Related Sleep Disorders

▪ The second type of apnoea, central sleep apnoea,

involves the complete cessation of respiratory
activity for brief periods and is often associated with
certain central nervous system disorders, such as
cerebral vascular disease, head trauma, and
degenerative disorders.
▪ Unlike people with obstructive sleep apnoea hypopnea
syndrome, those with central sleep apnoea wake up
frequently during the night but they tend not to
report excessive daytime sleepiness and often are
not aware of having serious breathing problem.
 Breathing-Related Sleep Disorders

▪ Because of the lack of daytime symptoms, people

tend not to seek treatment, so we know relatively little
about this disorder’s prevalence or course.
▪ The third breathing disorder, sleep-related
hypoventilation, is a decrease in airflow without a
complete pause in breathing.
▪ This tends to cause an increase in carbon dioxide
(CO2) levels, because insufficient air is exchanged
with the environment.
▪ All these breathing difficulties
interrupt sleep and result in
symptoms similar to those of
insomnia.
Breathing-Related Sleep Disorders
Breathing-Related Sleep Disorders
Breathing-Related Sleep Disorders
 Circadian Rhythm Sleep Disorder
Circadian Rhythm Sleep Disorder
▪ Circadian rhythm sleep disorder is characterized by
disturbed sleep (either insomnia or excessive
sleepiness during the day)
brought on by the brain’s
inability to synchronize its
sleep patterns with the
current patterns of day and night.
▪ Scientists identified several bodily rhythms that seem
to persist without cues from the environment,
rhythms that are self-regulated.
▪ Because these rhythms don’t exactly match our 24-
hour day, they are called circadian (from circa
meaning “about” and dian meaning “day”).
 Circadian Rhythm Sleep Disorder

▪ If our circadian rhythms don’t match the 24-hour

day, why isn’t our sleep completely disrupted over
time?
▪ Fortunately, our brains have a mechanism that keeps
us in sync with the outside world.
▪ Our biological clock is in the supra-chiasmatic
nucleus in the hypothalamus.
▪ Connected to the supra-chiasmatic nucleus is
a pathway that comes from our eyes.
▪ The light we see in the morning and the decreasing
light at night signal the brain to reset the biological
clock each day.
Circadian Rhythm Sleep Disorder
 Circadian Rhythm Sleep Disorder
▪ Unfortunately, some people have trouble sleeping
when they want to because of problems with their
circadian rhythms.
▪ The causes may be outside the person (for example,
crossing several time zones in a short amount of
time = jet lag) or because of internal dysfunction.
▪ Jet lag type circadian rhythm sleep disorder, as its
name implies, is caused by rapidly
crossing multiple time zones.
▪ People with jet lag usually report
difficulty going to sleep at the
proper time and feeling fatigued during the day.
▪ Traveling more than two time zones westward
usually affects people the most.
 Circadian Rhythm Sleep Disorder

▪ Shift work type circadian rhythm sleep disorder is

associated with work schedules.
▪ Many people, such as hospital employees, police, or
emergency personnel, work at
night or must work irregular hours;
as a result, they may have problems
sleeping or experience excessive
sleepiness during waking hours.
▪ Unfortunately, the problems of working (and thus
staying awake) at unusual times can go beyond
sleep and may contribute to cardiovascular disease,
ulcers, and breast cancer in women.
 Circadian Rhythm Sleep Disorder

▪ Sleep deprivation may provoke seizures and

mania. Depression and anxiety are also more
common in those with sleep deprivation.
▪ Almost two-thirds of all workers on rotating shifts
complain of poor sleep.
▪ In contrast with jet lag and shift work sleep-related
problems, which have external causes such as long-
distance travel and job selection, several circadian
rhythm sleep disorders seem to arise from within
the person experiencing the problems.
▪ Extreme night owls, people who stay up late and
sleep late, may have a problem known as delayed
sleep phase type.
 Circadian Rhythm Sleep Disorder

▪ Sleep is delayed or later than normal bedtime.

▪ At the other extreme, people with an advanced sleep
phase type of circadian rhythm disorder are “early
to bed and early to rise.” Here, sleep is advanced
or earlier than normal bedtime.
▪ Finally, two other types, irregular sleep–wake type
(people who experience highly varied sleep cycles)
and non-24-hour sleep–wake type (e.g., sleeping
on a 25- or 26-hour cycle with later and later
bedtimes ultimately going throughout the day),
illustrate the diversity of circadian rhythm sleep–
wake problems some people experience.
 Circadian Rhythm Sleep Disorder

▪ Scientists believe the hormone melatonin contributes

to the setting of our biological clocks that tell us
when to sleep.
▪ This hormone is produced by the
pineal gland, in the centre of the
brain.
▪ Melatonin has been nicknamed
the “Dracula hormone” because
its production is stimulated by darkness and ceases
in daylight.
▪ When our eyes see that it is night time, this
information is passed on to the pineal gland, which, in
turn, begins producing melatonin.
 Circadian Rhythm Sleep Disorder

▪ Researchers believe that both light and melatonin

help set the biological clock.
Circadian Rhythm Sleep Disorder
Circadian Rhythm Sleep Disorder
 Preventing Sleep Disorders

▪ Sleep experts generally agree that a significant

portion of the sleep problems people experience daily
can be prevented by following a few steps during the
day.
▪ Referred to as sleep hygiene, these changes in
lifestyle can be relatively simple to follow and can
help avoid problems such as insomnia for some
people.
▪ Some sleep hygiene recommendations rely on
allowing the brain’s normal drive for sleep to take
over, replacing the restrictions we place on our
activities that interfere with sleep.
 Preventing Sleep Disorders

▪ For example, setting a regular time to go to sleep

and awaken each day can help make falling asleep
at night easier.
▪ Avoiding the use of caffeine and
nicotine—which are both
stimulants—can also help
prevent problems such as
night time awakening.
▪ Although there is little controlled prospective
research on preventing sleep disorders, practicing
good sleep hygiene appears to be among the most
promising techniques available.
Preventing Sleep Disorders
 Parasomnias

▪ Parasomnias are not problems with sleep itself but

abnormal events that occur either during sleep or
during that twilight time between sleeping and
waking.
▪ Some events associated with parasomnia are not
unusual if they happen while you are awake (e.g.,
walking to the kitchen to look into the refrigerator) but
can be distressing if they take place while you are
sleeping.
▪ DSM-5 identifies a number of different parasomnias.
 Parasomnias

▪ As you might have guessed, Night-mares (or

Nightmare Disorder) occur during REM or dream
sleep.
▪ About 10% to 50% of children and
about 9% to 30% of adults
experience them regularly.
▪ To qualify as a nightmare disorder, according to
DSM-5 criteria, these experiences must be so
distressful that they impair a person’s ability to carry
on normal activities (such as making a person too
anxious to try to sleep at night).
▪ Some researchers distinguish nightmares from bad
dreams by whether or not you wake up as a result.
 Parasomnias

▪ Night-mares are defined as disturbing dreams that

awaken the sleeper; bad dreams are those that do
not awaken the person experiencing them.
▪ Nightmares are thought to be influenced by genetics,
trauma, medication use, and are associated with
some psychological disorders (e.g., substance
abuse, anxiety, borderline personality disorder, and
schizophrenia spectrum disorders).
▪ Disorder of arousal includes a number of motor
movements and behaviours during NREM sleep such
as sleepwalking, sleep terrors, and incomplete
awakening.
 Parasomnias

▪ Sleep Terrors, which most commonly afflict

children, usually begin with a
piercing scream.
▪ The child is extremely upset,
often sweating, and frequently
has a rapid heartbeat.
▪ On the surface, sleep terrors appear to resemble
nightmares—the child cries and appears
frightened—but they occur during NREM sleep and
therefore are not caused by frightening dreams.
▪ During sleep terrors, children cannot be easily
awakened and comforted, as they can during a
night-mare.
 Parasomnias

▪ Children do not remember sleep terrors, despite their

often dramatic effect on the observer.
▪ Approximately 6% of children (more boys than girls)
may experience sleep terrors; for adults, the
prevalence rate is approximately 2%.
▪ We know relatively little about sleep terrors, although
several theories have been proposed—including the
possibility of a genetic component, because the
disorder tends to occur in families.
▪ It might surprise you to learn that
Sleepwalking (also called Somnambulism)
occurs during NREM sleep.
 Parasomnias

▪ This means that when people walk in their sleep, they

are probably not acting out a dream.
▪ This parasomnia typically occurs
during the first few hours while a
person is in the deep stages of sleep.
▪ The DSM-5 criteria for sleepwalking
require that the person leave the bed,
although less active episodes can
involve small motor behaviours, such
as sitting up in bed and picking at the blanket or
gesturing.
 Parasomnias

▪ Because sleepwalking occurs during the deepest

stages of sleep, waking someone during an
episode is difficult; if the person is wakened, she
typically will not remember what has happened.
▪ It is not true, however, that waking a sleep-walker is
somehow dangerous.
▪ Sleepwalking is primarily a problem during
childhood, although a small proportion of adults
are affected.
▪ A relatively large number of children—from 15% to
30%—have at least one episode of sleep-walking,
with about 2% reported to have multiple incidents.
 Parasomnias

▪ Mostly, the course of sleepwalking is short, and few

people over the age of 15 continue to exhibit this
parasomnia.
▪ We do not yet clearly understand why some people
sleepwalk, although factors such as extreme fatigue,
previous sleep deprivation, the use of sedative or
hypnotic drugs, and stress have been implicated.
▪ On occasion, sleepwalking episodes have been
associated with violent behaviour, including
homicide and suicide.
▪ In one case, a man drove to his in-laws’ house,
succeeded in killing his mother-in-law, and
attempted to kill his father-in-law.
 Parasomnias

▪ He was acquitted of the charges of murder, using

sleepwalking as his legal defence.
▪ A related disorder, nocturnal eating syndrome, is
when individuals rise from their
beds and eat while they are still
asleep.
▪ This problem, which is different than
the night eating syndrome
discussed earlier in the chapter in the eating disorders
section, may be more frequent than previously
thought; it was found in almost 6% of individuals in
one study who were referred because of insomnia
complaints.
 Parasomnias

▪ Another uncommon parasomnia is sexsomnia;

acting out sexual behaviours such as masturbation
and sexual intercourse with no memory of the event.
▪ This rare problem can cause relationship problems
and, in extreme cases, legal problems when cases
occur without consent or with minors.
▪ There is an increasing
awareness that sleep is
important for both our mental
and our physical well-being.
 Parasomnias

▪ Sleep problems are also comorbid with many other

disorders and therefore can compound the
difficulties of people with significant psychological
difficulties.
▪ Researchers are coming closer to understanding
the basic nature of sleep and its disorders, and we
anticipate significant treatment advances in the
years to come.
Non-Rapid Eye Movement Sleep Arousal
Disorders
Nightmare Disorder
Rapid Eye Movement Sleep Behavior
Disorder
 References

▪ Barlow, D.H. & Durand, V.M. (2015), Abnormal

Psychology: An Integrative Approach (7th ed.).
Wadsworth.
▪ Barlow, D.H., Durand, V.M., du Plessis, L.M. & Visser,
C. (2017), Abnormal Psychology: An Integrative
Approach (1st South African ed.). Wadsworth.