Eating and Sleep-Wake Disorders

Reporters:
Dumagay, Mary Rodeline
Fulache, Lei Angeline

I. Major Types of Eating Disorders

Eating disorder cases began to increase in the 1950s or early 1960s and spread quickly
over the next decades.
A. Bulimia Nervosa
- Out-of-control eating episodes (binges) followed by self-induced
vomiting, excessive use of laxatives, or other attempts to purge the
food.
● Clinical Description (criterion)
1. Hallmark of bulimia nervosa is eating a larger amount of food than
most people eat under similar circumstances (Fairburn & Cooper,
1993, in press).
2. Eating is experienced as out of control (Franko, Wonderlich, Little, &
Herzog, 2004).
3. Individuals attempt to compensate for the binge eating and potential
weight gain, almost always by purging techniques.
- Purging 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 individuals undergo excessive exercise (rigorous exercise is
more usual in anorexia nervosa; According to Davis et al., 1997, 57%
of a group of patients with bulimia nervosa exercised excessively while
81% of a group of patients with anorexia nervosa did).
- Some individuals fast for long periods between binges.
- Subtype of bulimia nervosa in the DSM-IV-TR
1. Purging Type - vomiting, laxatives, or diuretics
2. Non-purging Type - exercise and/or fasting; quite rare
accounting to only 6% - 8% of patients with bulimia.
 (Studies found little evidence of any differences between these two subtypes
nor in their severity of psychopathology, frequency of binge episodes, or
prevalence of major depression and panic disorder. Hence, it was dropped in
the DSM-5.)
- Notes: Purging is not a particularly efficient method of reducing
caloric intake. Vomiting reduces approximately 50% of the calories
just consumed and less if it is delayed. Laxatives and related
procedures have little effect so long after the binge.
● Diagnostic Criteria for Bulimia Nervosa
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, 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 (a feeling that
one cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviour in order to prevent
weight gain, such as self-induced vomiting; misuse of laxatives;
diuretics or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviour both
occur, on average, at least once 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.
● Medical Consequences
1. Salivary gland enlargement caused by repeated vomiting.
2. Repeated vomiting may erode the dental enamel on the inner surface of
the front teeth and may tear the esophagus.
3. Continued vomiting may upset the chemical balance of bodily fluids,
including sodium and potassium levels (electrolyte imbalance) - can
result to cardiac arrhythmia, seizures, and renal/kidney failure.
4. Young women with bulimia may develop more body fat than age- wnd
weight-match healthy controls.
 5. Intestinal problems can result from laxative abuse (can include severe
constipation or permanent colon damage).
6. Individuals with bulimia have marked calluses on their fingers or the
backs of their hands caused by the friction of contact with the teeth and
throat when they stick their fingerd down their throat to stimulate gag
reflex.
● Associated Psychological Disorders
- 80.6% of individualsxwith bulimia had an anxiety disorder at some
point in their lives; 66% of adolescents with bulimia presented with
co-occuring anxiety disorder when interviewed.
- Mood disorders (depression) commonly co-occur with bulimia. 20% of
bulimic patients meet the criteria for a mood disorder and between
50% and 70% meeting criteria at some point during the course of their
disorder.
- Substance abuse commonly accompanies bulimia nervosa.
- Wade, Bulik, Prescott, and Kendler (2004) found that shared risk
factors of novelty seeking and emotional instability accounted for the
high rates of comorbidity between bulimia and anxiety and substancd
use disorder (but differs somewhat between males and females).
B. Anorexia Nervosa
- A person eats nothing beyond minimal amounts of food so body
weight sometimes drops dangerously.
- Anorexia literally means "nervous loss of appetite" which is an
incorrect definition because appetite often remains healthy.
- Majority of individuals with bulimia are within 10% of their normal
weight. Whereas, individuals with anorexia are so successful at losing
weight that they put their lives in considerable danger.
- Major difference of bulimia and anorexia nervosa: whether the
individual is successful at losing weight. People with anorexia are
proud of their diets and extraordinary control. People with bulimia are
ashamed of their eating issues and their lack of control.
● Clinical Description
- Anorexia nervosa is less common than bulimia. Many individuals with
bulimia have a history of anorexia.
 - People with anorexia have an intense fear of obesity and relentlessly
pursue thinness.
- Diagnostic Criteria for Anorexia Nervosa
A. Restriction of energy intake relative to requirements, leading to
a significantly low body weight in the context of age, sex,
developmental trajectory, and physical health. Significantly low
weight is defined as a weight that is less than minimally
normal, or for children and adolescents, less than minimally
expected.
B. Intense fear of gaining weight or of becoming fat, or persistent
behavior that interferes with weight gain, even though at a
significantly low weight.
C. Disturbances in the way in which one's body weight or shape is
experienced, undue influence of body weight or shape on
self-evaluation, or persistent lack of recognition of the
seriousness of the current low body weight.
Specify type:
Restricting type: During the last 3 months, the individual has
not engaged in recurrent episodes of binge eating or purging
behavior. This subtype describes presentations in which weight
loss is accomplished primarily through dieting, fasting, and/or
excessive exercise.
Binge-eating/purging type: During the last 3 months, the
individual has engaged in recurrent episodes of binge-eating or
purging behavior.
● Medical Consequences
- Cessation of menstruation (amenorrhea); dropped as a diagnostic
criterion in DSM-5.
- Dry skin, brittle hair or nails, and sensitivity to or intolerance of cold
temperatures.
- Lanugo or downy hair on the limbs and cheeks.
- Cardiovascular problems (low blood pressure and heart rate)
- If vomiting is part of the anorexia, electrolyte imbalance and resulting
cardiac and kidney problems can result.
 ● Associated Psychological Disorders
- Anxiety disorders and mood disorders are often present in individuals
with anorexia.
- Obsessive-compulsive disorder seems to co-occur often with anorexia.
- Substance abuse is common in individuals with anorexia nervosa and,
in conjunction with anorexia, is a strong predictor of mortality,
particularly by suicide.
C. Binge-Eating Disorder
- Individuals may binge repeatedly and find it distressing, but they do
not attempt to purge food.
- Classified in DSM-IV as a disorder needing further study, BED is now
included as a full-fledged disorder in DSM-5.
- Greater likelihood of occurring in males and at a later age of onset.
- Greater likelihood of remission and a better response to treatment
compared with other eating disorders.
● Diagnostic Criteria for Binge-Eating Disorder
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 (e.g. 2-hour period) an amount of
food that is definitely larger than what most people would eat in a
similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode.
B. The binge-eating episodes are associated with three (or more) of the following:
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is
eating.
5. Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
D. Binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate
compensatory behaviour as in bulimia nervosa and does not occur exclusively during the
course of bulimia nervosa or anorexia nervosa.
D. Statistics
- Bulimia nervosa was recognized as a distinct psychological disorder only in
the 1970s.
- 90% to 95% of individuals with bulimia are women. Males with bulimia have
slightly later age of onset, and a large minority are predominantly gay males or
bisexual (42%).
- Another large group of males with eating disorders are male athletes in sports
that require weight regulation.
- A 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.
- Results from the National Comorbidity Survey reflect lifetime and 12-month
prevalence, not only for the three major eating disorders described here but
also for the "subthreshold" BED, where binge eating occurred at a
high-enough frequency but some additional criteria such as marked distress
regarding the binge eating, were not met. If binge eating occurred at least
twice a week for 3 months, the case was listed under "any binge eating."
- The median age of onset for all eating-related disorders occurred in a narrow
range of 18 to 21 years.
- For anorexia, the age of onset is fairly consistent with younger cases tending
to begin at 15. For bulimia, it was more common for its cases to begin as early
as age 10.
- Once bulimia develops, it tends to be chronic if untreated. One study shows
that the "drive for thinness" and accompanying symptoms are still present in a
group of women 10 years after the diagnosis.
- Fairburn and colleagues (2000) identified a group of 102 females with bulimia
nervosa and followed 92 of them prospectively for 5 years. About a third
improved to the point where they no longer met diagnostic criteria each year,
but another third who had improved previously relapsed.
- The strongest predictors of persistent bulimia were a history of childhood
obesity and a continuing overemphasis on the importance of being thin
(Fairburn, Stice, et al., 2003).
- Individuals with anorexia nervosa tend to maintain a low BMI over a long
period, along with distorted perceptions of shape and weight, indicating that
 even if they no longer meet criteria for anorexia they continue to restrict their
eating.
● Cross-Cultural Considerations
- Anorexia and bulimia was found to develop in immigrants who have recently
moved to Western countries.
- In Nasser's survey of 50 Egyptian women in London universities and 60
Egyptian women in Cairo universities, 12% of the Egyptian women in
England had developed eating disorders.
- Mumford, Whitehouse, and Platts (1991) found comparable results with Asian
women living in the United States.
- Earlier surveys revealed that African American adolescent girls have less body
dissatisfaction, fewer weight concerns, a more positive self-image, and
perceive themselves to be thinner than they are, compared with the attitudes of
Caucasian adolescent girls.
- In Curacao in the Netherlands Antilles, the incidence of anorexia from 1995 to
1998 was zero among the majority black population but approached levels
observed in the Netherlands and United States for the minority white and
mixed population.
- Anorexia and bulimia are relatively homogeneous and both were
overwhelmingly associated with Western cultures until recently.
● Developmental Considerations
- Anorexia and bulimia are strongly related to development. Differential
patterns of physical development in girls and boys interact with cultural
influences to create eating disorders.
- Eating disorders, particularly anorexia nervosa, occasionally occur in children
under the age of 11. They are likely to restrict fluid intake and food intake.
- Negative attitude toward being overweight emerges as early as 3 years of age
and more than half of girls 6-8 would like to be thinner. By 9 years of age,
20% of girls reported trying to lose weight, and by 14, 40% were trying to lose
weight.
- At 55, both bulimia and anorexia can occur.
II. Causes of Eating Disorders
A. Social Dimensions
- Anorexia and particularly bulimia are the most culturally specific
psychological disorders yet identified.
- Levine and Smolak (1996) refer to the "glorification of slenderness" in
magazines and on television. Because overweight men are 2 to 5 times more
common as television characters than overweight women, the message from
the media to be thin is clearly aimed at women and the message gets through
loud and clear.
- Thompson and Stice (2001) found that the risk for developing eating disorders
was directly related to the extent to which women internalize or buy into
media messages and images glorifying thinness.
- Fallon and Rozin (1985) found that men rated their current size, their ideal
size, and the size they figured would be most attractive to the opposite sex as
approximately equal; they rated their ideal body weight as heavier than the
weight females thought most attractive in men. Women rated their current
figure as much heavier than what they judged the most attractive, which in
turn was rated as heavier than what they thought was ideal.
- Pope and colleagues (2000) confirmed that men generally desire to be heavier
and more muscular than they are.
- Paxton, Schutz, Wertheim, and Muir (1999) found that there are friendship
cliques that are significantly associated with individual body image concerns
and eating behaviors. If your friends tend to use extreme dieting or other
weight loss techniques, there is a greater chance that you will too.
- A recent, more definitive study concludes that friendship cliques do not
necessarily cause these attitudes or the disordered eating that follows. Rather,
adolescent girls simply tend to choose friends who already share these
attitudes.
- In one early study, toddlers with affluent parents appeared at hospitals with
"failure to thrive" syndrome, in which growth and development are severely
retsrded because of inadequate nutrition. In each case, the parents had put their
young healthy toddlers on diet in the hope of preventing obesity at a later date.
- Mothers who have anorexia restrict food intake in not only themselves, but
also their children.
- Patton, Johnson-Sabine, Wood, Mann, and Wakeling (1990) determined that
adolescent girls who dieted were 8 times more likely to develop an eating
disorder 1 year later than those who weren't dieting.
- Stice and colleagues (1999) demonstrated that one of the reasons attempts to
lose weight may lead to eating disorders is that weight-reduction efforts in
adolescent girls are more likely to result in weight gain than weight loss.
- Cottone et. al. (2009) began feeding rats junk food which the rats came to
love, instead of a boring diet of pellets. When the junk food were withdrawn,
the rats became extremely stressed and anxious. They began to eat more of the
pellets to relieve the stress. Thus, repeated cycles of "dieting" seems to
produce stress-related withdrawal symptoms in the brain resulting in more
than would have occurred without dieting.
- Fairburn, Cooper, Doll, and Davies (2005) identified several risk factors for
developing eating disorders. Those most at risk were already binge eating and
purging, were eating in secret, expressed a desire to have an empty stomach,
were preoccupied with food, and were afraid of losing control over eating.
- Reverse Anorexia Nervosa occurs in men particularly male weight lifters. Men
with this syndrome reported they were extremely concerned about looking
small even though they were muscular.
- Dietary Restraint
- If cultural pressures to be thin are as important as they seem to be in
triggering eating disorders, then such disorders would be expected to
occur where these pressures are particularly severe.
- Keys and colleagues (1950) conducted a semistarvation experiment
involving 36 conscientious objectors who volunteered for the study as
an alternative to military service. For 6 months these healthy men were
given about half their former full intake of food. It was followed by a
3-month rehabilitation phase where food was gradually increased. The
investigators found that the participants became preoccupied with food
and eating.
- Dieting is one factor that can contribute to eating disorders and along
with dissatisfaction with one's body, is a primary risk factor for later
eating disorders.
- Family Influences
 - The "typical" family of someone with anorexia is successful,
hard-driving, concerned about external appearances, and eager to
maintain harmony. They deny or ignore conflicts or negative feelings
and tend to attribute their problems to other people at the expense of
frank communication.
- Mothers of girls with disordered eating seemed to act as "society's
messengers" in wanting their daughters to be thin; more likely to be
perfectionist, dieting themselves, less satisfied with their families and
family cohesion.
● Biological Dimensions
- Relatives of patients with eating disorders are 4 to 5 times more likely than the
general population to develop eating disorders themselves, with the risk for
female relatives of patients with anorexia higher.
- Hsu (1990) and Steiger et al. (2013) speculate that nonspecific personality
traits such as emotional instability and poor impulse control might be
inherited. A person might inherit a tendency to be emotionally responsive to
stressful life events and might eat impulsively in an attempt to relieve stress
and anxiety. These biological vulnerabilities might then interact with social
and psychological factors to produce eating disorders.
- Low levels of serotonergic activity is associated with eating disorders and are
associated with impulsivity generally binge eating. Most drugs under study as
treatments for eating disorders target the serotonin system.
● Psychological Dimensions
- Women with eating disorders have a diminished sense of personal control and
confidence in their own abilities and talents; might manifest as strikingly low
self-esteem. They display perfectionistic attitudes (learned or inherited) which
may reflect attempts to control over important events in their lives.
- When perfectionism is directed to distorted perception of body image, a
powerful engine to drive eating disorder behavior is in place.
- Women with eating disorders are intensely preoccupied with how they appear
to others.
- They perceive themselves as frauds for false impressions of being adequate,
self-sufficient, or worthwhile. They feel impostors in their social groups and
experience heightened levels of social anxiety.
 - Rosen and Leitenberg (1985) observed substantial anxiety before and during
snacks which they theorized is relieved by purging.
- Some of the patients have difficulty tolerating any negative emotion and may
binge or engage in other behaviors (self-induced vomiting or intense exercise)
in an attempt to regulate their mood.
● An Integrative Model
- Individuals with eating disorders may have some of the same biological
vulnerabilities (being highly responsive to stressful life events) as individuals
with anxiety disorders.
- Anxiety and mood disorders are common in the families of individuals with
eating disorders.
- We could conceptualize eating disorders as anxiety disorders focused solely on
a fear of becoming overweight.
- Social and cultural pressures to be thin motivate significant restriction of
eating, usually through severe dieting.
- Social interactions in high-achieving families play some role. Families on
looks and achievement and perfectionistic tendencies may help establish
strong attitudes about the overriding importance of physical appearance to
popularity and success, attitudes reinforced in peer groups.
III. Treatment of Eating Disorders
A. Drug Treatments
- Drug treatments have not been found to be effective in the treatment of
anorexia nervosa.
- There is some evidence that drugs may be useful for some people with bulimia
especially during the bingeing and purging cycle.
- The Food and Drug Administration (FDA) in 1996 approved Prozac as
effective for eating disorders. Effectiveness is measured by reductions in the
frequency of binge eating and by the percentage of patients who stop binge
eating and purging altogether.
- Antidepressant drugs alone do not have substantial long-lasting effects on
bulimia nervosa.
B. Psychological Treatments
- Psychological treatments for people with eating disorders were directed at the
patient's low self-esteem and difficulties in developing an individual identity.
 - Short-term cognitive-behavioural treatments target problem eating behavior
and associated attitudes about the overriding importance and significance of
body weight and shape and became the treatment choice of bulimia. This
approach has been improved in two ways:
1. Variety of new procedures intended to improve outcomes have been
added.
2. Noting the common concern of body shape and weight at the core of
all eating disorders, the treatment has become transdiagnostic in that it
is applicable with minor variations to all eating disorders.
(the principal focus of this protocol is on the distorted evaluation of
body shape and weight, and maladaptive attempts to control weight in
the form of strict dieting, possibly accompanied by binge eating, and
methods to compensate for overeating such as purging, laxative
misuse, etc. Fairburn refers to this treatment as cognitive-behavioral
therapy-enhanced or CBT-E).
● Bulimia Nervosa
- In the CBT-E pioneered by Fairburn, the first stage is teaching the patient the
physical consequences of binge eating and purging, as well as the
ineffectiveness of vomiting and laxative abuse for weight control.
- In later stages of the treatment, CBT-E focuses on altering dysfunctional
thoughts and attitudes about body shape, weight, and eating.
- Coping strategies for resisting the impulse to binge and/or purge are also
developed, including arranging activities so that the individual will not spend
time alone after eating during the early stages of treatment.
- Agras, Walsh, Fairburn, Wilson, and Kraemer (2000) randomly assigned 220
patients meeting diagnostic criteria for bulimia nervosa to 19 sessions of either
cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT)
focused on improving interpersonal functioning.
- The investigators found that CBT was significantly superior to IPT at the end
of the treatment, with 45% recovered in the CBT group versus 8% in the IPT
group.
- The percentage who remitted was 67% in the CBT group vs. 40% in the IPT
group. After 1 year, the differences were no longer significant as IPT group
patients tended to catch up with those in the CBT group.
 - The investigators concluded that CBT is the preferred psychological treatment
for bulimia nervosa because it worked significantly faster.
- Now, results from a major clinical trial comparing 20 weeks of CBT-E with 2
years of weekly long-term psychoanalytic psychotherapy (PPT) in 70 patients
with bulimia are available; both treatments resulted in improvements and
patients in each group were comfortable with their treatment, but at 5 months
42% of CBT-E patients were recovered compared to 6% of PPT patients.
- Integrating family and interpersonal strategies into CBT is a promising new
direction.
- Combining drugs with psychosocial treatments might boost the overall
outcome.
- CBT was significantly superior to supportive psychotherapy in the treatment
of bulimia nervosa; adding two antidepressants medications to CBT, including
a selective-serotonin reuptake inhibitor (SSRI), modestly increased the benefit
of CBT.
● Binge-Eating Disorder
- Early studies adapting CBT for bulimia to obese binge eaters were quite
successful.
- 93 obese individuals with BED underwent treatment with CBT and after a
year, 41% of the participants abstained from bingeing and 72% binged less
frequently. After 1 year, binge eating was reduced by 64% and 33% of the
group refrained from bingeing altogether.
- In contrast to results with bulimia, it appears that IPT is every bit as effective
as CBT for binge eating.
- In a study examining the effectiveness of the antidepressant drug Prozac
compared with CBT for CED, Prozaz was ineffective and did not add anything
to CBT when the two treatments were combined.
- Widely available weight loss programs for obese patients with BED such as
Weight Watchers have some positive effect on bingeing (but not nearly as
much as CBT).
- Some racial and ethnic differences are apparent in people with BED seeking
treatment; African American participants tend to have higher BMI and
Hispanic participants have greater concerns with shape and weight than
Caucasian participants.
 - Self-help approach should probably be the first treatment offered for BED
before engaging in more expensive and time-consuming therapist-led
treatments.
- If an obese person is binge-eating, standard weight loss procedures will be
ineffective without treatment directed at bingeing.
● Anorexia Nervosa
- The most important initial goal in anorexia is to restore the patient's weight to
a point that is at least within the low-normal range.
- Inpatient treatment is recommended if body weight is below 85% of the
average healthy body weight for a given individual or if weight has been lost
rapidly and the individual continues to refuse food.
- If weight loss has been more gradual and seems to have stabilized, weight
restoration can be accomplished on an outpatient basis.
- The easiest part of the treatment is to restore the weight.
- Initial weight gain is a poor predictor of long-term outcome in anorexia.
Without attention to the patient's underlying dysfunctional attitudes about
body shape and interpersonal disruptions in her life, she will almost always
relapse.
- For restricting anorexics, the focus of the treatment must shift to their marked
anxiety over becoming obese and losing control of eating as well as to their
undue emphasis on thinness as a determinant of self-worth, happiness, and
success. The treatment effective for this is the transdiagnostic approach
CBT-E.
- Must include the family to accomplish two goals:
1. The negative and dysfunctional communication in the family regarding
food and eating must be eliminated and meals must be made more
structured and reinforcing.
2. Attitudes toward body shape and image distortion are discussed at
some length in family sessions.
- Family therapy directed at the goals mentioned seems effective particularly
with young girls with a short history of the disorder.
C. Preventing Eating Disorders
- It is necessary to target specific behaviors to change before implementing a
prevention program.
 - In the review of Stice, Shaw, and Marti (2007), selecting girls at age 15 or
over and focusing on eliminating an exaggerated focus on body shape or
weight and encouraging acceptance of one's body stood the best chance of
success in preventing eating disorders.
- Using the "selective approach", Stice et al. (2012) developed a program called
"Healthy Weight", the women were educated about food and eating habits
during a 4 weekly hour-long group sessions with 6-10 participants.
- Winzelberg and colleagues (2000) developed the "student bodies program"
which is a structured, interactive health education program designed to
improve body image satisfaction and delivered through the Internet. The
program was markedly successful, because participants, compared to controls,
reported a significant improvement in body image and a decrease in drive for
thinness.
- "The Body Project", a briefer and more efficient program has now been
adapted as a standalone intervention delivered over the Internet with no
clinician required.
IV. Obesity
● Statistics
- Between 2000 and 2010, the proportion of adults in the United States with a Body
Mass Index (BMI) of 30 or higher, indicating obesity, increased steadily. Specifically,
the prevalence of obesity rose from 30.5% in 2000 to 35.7% in 2010, with
incremental increases in between these years. Interestingly, there was no significant
difference in the prevalence of obesity between men and women during this time
period. These findings were reported by Flegal et al. (2010, 2012) and Ogden et al.
(2006).
- For children and adolescents, the numbers are even worse, with the number of
overweight youngsters tripling in the past 25 years (Critser, 2003).
- Over the past ten years, there has been a rise in the obesity rates among children
aged 2 to 19 years old who have a body mass index (BMI) above the 95th percentile
for their sex and age.
- Additionally, the case of Obesity is not limited to North America.

● Disordered Eating Patterns in Cases of Obesity

 - According to Lundgren, Allison, and Stunkard (2012) and Striegel-Moore, Franko,
& Garcia (2009), there are two forms of maladaptive eating patterns in people who
are obese. The first is binge eating, and the second is night eating syndrome.
- The pattern of night eating syndrome is interesting because it occurs in between 6%
and 16% of obese individuals seek- ing weight-loss treatment but in as many as 55%
of those with extreme obesity seeking bariatric surgery.
- Based on Lundgren et al., 2012; Striegel-Moore and colleagues (2010), patients with
this disorder do not binge during their night eating and seldom purge. Occasionally,
nonobese individuals will engage in night eating, but the behavior is overwhelmingly
associated with being overweight or obese.
- Night eating syndrome is an important target for treatment in any obesity program to
reregulate patterns of eating.

● Causes
- Henderson, together with Brownell (2004) make a point that this obesity epidemic is
clearly related to the spread of modernization.
- Kelly Brownell (2003; Brownell et al., 2010; Gearhardt et al., 2012) notes that in our
modern society individuals are continually exposed to heavily advertised, inexpensive
fatty foods that have low nutritional value.
- According to studies, not everyone exposed to the modernized environment such as
that in the United States becomes obese, and this is where genetics, physiology, and
personality come in.
- On average, genetic contributions may constitute a smaller portion of the cause of
obesity than cultural factors, but it helps explain why some people become obese and
some don’t when exposed to the same environment.
- According to Gearhardt and colleagues (2011), individuals with addictive obese
eating behavior, including less control over eating and feelings of withdrawal if access
to food is limited, show similar patterns of reward neurocircuitry in the brain as do
those with substance abuse.
- Many of these attitudes as well as eating habits are strongly influenced by family
and close friends.

● Treatment
 - According to Bray (2012), the treatment of obesity is only moderately successful at
the individual level.
- Treatment is usually organized in a series of steps from least intrusive to most
intrusive depending on the extent of obesity.
- The most usual result is that some individuals may lose some weight in the short
term but almost always regain that weight.
- Several studies have compared the most popular diet programs, such as the Atkins
(carbohydrate restriction), Ornish (fat restriction), Zone (macronutrients balance), and
Weight Watchers (calorie restriction) diets.
- The most successful programs are professionally directed behavior modification
programs, particularly if patients attend group maintenance sessions periodically in
the year following initial weight reduction (Bray, 2012; Wing, 2010).
- It is highly recommended for individual who are dangerously obese to have a
very-low-calorie diets and possibly drugs, combined with behavior modification
programs.
- According to Adams et al., (2012); Courcoulas (2012); Livingston (2012), the
surgical approach to extreme obesity— called bariatric surgery, is an increasingly
popular approach for individuals with a BMI of at least 40.

V. Sleep-Wake Disorders: The Major Dyssomnias

● An Overview of Sleep–Wake Disorders
- According to Charland (2008), for a considerable period of time, the examination of
sleep patterns has impacted the understanding of abnormal psychology. In the 19th
century, the treatment of individuals with severe mental illness involved a technique
called "moral treatment," which involved incorporating adequate sleep as part of the
therapy.
- Researchers who prevented people from sleeping for prolonged periods found that
chronic sleep deprivation often had profound effects.
- A number of the disorders covered in this book are often associated with sleep
complaints, including autism spectrum disorder, schizophrenia, major depression,
bipolar disorder, and anxiety-related disorders.
- Rapid Eye Movement (REM) sleep refers to the region of the brain that is involved
with our dream sleep.
 - According to Wiebe and colleagues (2012), sleep deprivation has temporary
antidepressant effects on some people, although in people who are not already
depressed sleep deprivation may bring on a depressed mood.

Two Major Categories of Sleep-Wake Disorders:

A. Dyssomnias
- This disorder usually involves difficulties in getting enough sleep, problems with
sleeping when you want to and complaints about the quality of sleep, such as not
feeling refreshed even though you have slept the whole night.
B. Parasomnias
- This disorder is characterized by abnormal behavioral or physiological events that
occur during sleep, such as nightmares and sleepwalking.

● Insomnia Disorder
- This disorder is one of the most common sleep–wake disorders which causes an
individual to have trouble falling asleep, staying asleep, or getting a good quality of
sleep.

● Clinical Description
- Based on Sonja’s case, her symptoms meet the DSM-5 criteria for insomnia disor-
der because her sleep problems were not related to other medical or psychiatric
problems (also referred to as primary insomnia).
- Sonja’s is a typical case of insomnia disorder since she had trouble both initiating
and maintaining sleep.

B. Statistics
- According to Roth and colleagues (2011), almost a third of the population reports
some symptoms of insomnia during any given year and for many individuals, sleep
difficulties are a lifetime affliction (Mendelson, 2005).
- There’s a number of psychological disorders associated with insomnia. Total sleep
time often decreases with depression, substance use disorders, anxiety disorders, and
neurocognitive disorder due to Alzheimer’s disease.
- Women report insomnia twice as often as men since women more often report
problems initiating sleep which may be a result of hormonal differences.
 - Usually, children who have difficulty falling asleep usually throw a tantrum at
bedtime or do not want to go to bed.
- According to the National Sleep Foundation (2009), a national sleep poll revealed
that among adults from 55 to 64 years of age, 26% complain of sleep problems, but
this decreases to about 21% for those from 65 to 84 years.

● Causes
- Insomnia is a common occurrence in various medical and psychological conditions,
such as pain, physical discomfort, lack of daytime physical activity, and respiratory
issues. In some cases, insomnia may be linked to disturbances in the body's internal
biological clock and its regulation of body temperature.
- Among the other factors that can interfere with sleeping are drug use and a variety of
environmental influences such as changes in light, noise, or temperature.
- Other sleep disorders, such as sleep apnea (a disorder that involves obstructed
nighttime breathing) or periodic limb movement disorder (excessive jerky leg
movements), can cause interrupted sleep and may seem similar to insomnia.
- Also, various psychological stresses can also disrupt your sleep.

● An Integrative Model
- An integrative view of sleep disorders includes several assumptions such as both
biological and psychological factors are present in most cases. A second assumption
is that these multiple factors are reciprocally related.
- Rebound Insomnia happens when sleep reappears, sometimes worse- may occur
when the medication is withdrawn.

● 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”).
- Several factors that can cause excessive sleepiness would not be considered
hypersomnolence.
- Another sleep problem that can cause a similar excessive sleepiness is a
breathing-related sleep disorder called sleep apnea. People with this problem have
difficulty breathing at night.
 ● Narcolepsy
- This disorder is described to be a different form of the sleeping problem in which
individuals who have this disorder feel very drowsy during the day.
- Additionally, some people with narcolepsy experience 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.

Two other characteristics distinguish people who have narcolepsy (Ahmed & Thorpy, 2012):
1. Individuals who have narcolepsy commonly report sleep paralysis, a brief period
after awakening when they can’t move or speak that is often frightening to those who
go through it.
2. Another characteristic of narcolepsy is hypnagogic hallucinations, vivid and often
terrifying experiences that begin at the start of sleep and are said to be unbelievably
realistic because they include not only visual aspects but also touch, hearing, and even
the sensation of body movement.

● Breathing-Related Sleep Disorders

- According to Overeem and Reading (2010), 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 asleep.
- 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.

Three types of apnea:

1. Obstructive sleep apnea hypopnea syndrome
- This occurs when airflow stops despite continued activity by the respiratory system
(Mbata & Chukwuka, 2012).
2. Central sleep apnea
- This 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 (Badr, 2012).
3. Sleep-related hypoventilation
- This is a decrease in airflow without a complete pause in breathing.
 ● Circadian Rhythm Sleep Disorder
- This 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.
- Our biological clock is in the suprachiasmatic nucleus in the hypothalamus.
Connected to the suprachiasmatic nucleus is a pathway that comes from our eyes.

Types of Circadian Rhythm Sleep Disorder:

1. Jet Lag Type- As its name implies, caused by rap- idly crossing multiple time zones
(Kolla, Auger, & Morgenthaler, 2012).
2. Shift Work Type- Sleep problems that are associated with work schedules
(Åkerstedt & Wright Jr., 2009).
3. Delayed Sleep Phase Type- Sleep is delayed or later than normal bedtime.
4. Advanced Sleep Phase Type- A disorder in which individuals are “early to bed and
early to rise.”
5. 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).

VI. Treatment of Sleep Disorders

● Medical Treatments
- People who complain of insomnia to a medical professional are likely prescribed
one of several benzodiazepine or related medications which include short-acting drugs
such as triazolam (Halcion), zaleplon (Sonata), and zolpidem (Ambien) and
long-acting drugs such as flurazepam (Dalmane).
- There are also newer medications found that work directly with the melatonin
system (e.g., ramelteon [Rozerem]), are also being developed to help people fall and
stay asleep.
- According to Morgenthaler and Silber (2002), a newer concern for some
medications (e.g., Ambien) is that they may increase the likelihood of
sleep-walking-related problems, such as sleep-related eating disorder.
- To help people with hypersomnolence or narcolepsy, physicians usually prescribe a
stimulant such as methylphenidate (Ritalin, the medication Ann was taking) or
modafinil (Nevsimalova, 2009).
 - On the other hand, Cataplexy, or loss of muscle tone, can be treated with
antidepressant medication, not because people with narcolepsy are depressed, but
because antidepressants suppress REM (or dream) sleep. Also, sodium oxybate is
recommended to treat cataplexy (Morgenthaler et al., 2007).
- An interesting treatment for people with mild apnea is being explored by researchers
in collaboration with a Swiss didgeridoo instructor.

● Environmental Treatments
- One general principle for treating circadian rhythm disorders is that phase delays
(moving bedtime later) are easier than phase advances (moving bedtime earlier).
- Another strategy to help people with sleep problems involves using bright light to
trick the brain into readjusting the biological clock.
- Research indicates that bright light (also referred to as phototherapy) may help
people with circadian rhythm problems readjust their sleep patterns (Kolla et al.,
2012).

● Psychological Treatments
- Research shows that some psychological treatments for insomnia may be more
effective than others.

Psychological Treatments for Insomnia:

❖ Cognitive- This approach focuses on changing the sleepers’ unrealistic expectations
and beliefs about sleep.
❖ Guided Imagery Relaxation- This approach uses meditation or imagery to help with
relaxation at bedtime or after a night waking.
❖ Graduated Extinction- This treatment instructs the parent to check on the child after
progressively longer periods until the child falls asleep on his or her own.
❖ Paradoxical intention- This technique involves instructing individuals in the opposite
behavior from the desired outcome.
❖ Progressive relaxation- This technique involves relaxing the muscles of the body in an
effort to introduce drowsiness.

● Preventing Sleep Disorders

 - According to research and sleep professionals, sleep problems can be prevented by
following sleep hygiene- described as the changes in lifestyle that can be relatively
simple to follow and can help in avoiding problems such as insomnia for some
individuals (Goodman & Scott, 2012).
- Establishing good sleeping habits may also be helpful such as maintaining a good
sleeping routine, eliminating all foods and drinks that contain caffeine 6 hours before
bedtime, limiting the use of alcohol and tobacco, eating a healthy balanced diet, and
many more.

● Parasomnias and their Treatment

- Parasomnias are not problems with sleep itself but abnormal events that occur either
during sleep or during that twilight time between sleeping and waking.

Different Parasomnias as Identified by DSM-5:

❖ Nightmares (Nightmare Disorder)- Occur during REM or dream sleep (Augedal,
Hansen, Kronhaug, Harvey, & Pallesen, 2013). Also, 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).
❖ Sleep Terrors- This type most commonly afflicts children, usually begins with a
piercing scream and occurs during NREM sleep.
❖ Sleepwalking (somnambulism)- Occurs during NREM sleep. 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.
❖ Nocturnal Eating Syndrome- Happens when individuals rise from their beds and eat
while they are still asleep (Striegel-Moore et al., 2010).