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7 Sleep-Wake and Eating Disorders

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Chapter Objectives

After reading this chapter, you should be able to do the following:

• Describe the stages of the normal sleep cycle.

• Know and describe the main differences between the major sleep-wake disorders.

• Understand the main ways to treat sleep disorders.

• Know and describe the main feeding disorders.

• Know and describe the major differences between anorexia nervosa, bulimia nervosa, and binge-eating disorder.

• Describe some of the methods used to treat eating disorders.

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7.1 An Introduction to Sleep-Wake Disorders: The Normal Sleep Cycle

We sleep close to 3,000 hours per year, which means that we spend about one third of our lives asleep. However, according to the National Sleep Foundation (2017), about 40% of people in the United States don’t get enough sleep, and lack of proper sleep can lead to health problems (Depner, Stothard, & Wright, 2014; Liu, 2016; Schochat, Cohen-Zion, & Tzischinsky, 2013).

The normal human sleep cycle consists of four different stages of sleep, one of which involves rapid eye movement (REM) and three of which do not (non-REM, or NREM, sleep). The cycle begins with NREM Stage 1, which begins shortly after you fall asleep. In this stage, which lasts from 1 to 10 minutes, you are lightly asleep. However, you can quickly and somewhat easily return to being fully awake. Although you are asleep, you may wake up from this stage feeling like you didn’t sleep at all. The next stage is NREM Stage 2. This stage lasts about 20 minutes and is characterized by a slowing heart rate and a decrease in body temperature. You spend about 45% of your sleep time in NREM Stage 2 sleep. Your body reduces its activity to prepare you to go into a deep sleep, and it becomes harder to wake you up. Typically, NREM Stages 1 and 2 are referred to as light sleep. NREM Stage 3 comes next. This stage is the combination of what was previously separated into Stage 3 and 4 sleep and typically starts 35 to 45 minutes after falling asleep. Your brain waves slow down and become larger. In this stage, you will sleep through most potential sleep disturbances (noises and movements) without showing any reaction. If by some chance you actually wake up during NREM Stage 3 sleep, there is a good chance that you will feel disoriented for the first few minutes. Sometimes this stage is referred to as “slow-wave sleep” or “delta sleep.”

The final stage of a normal sleep cycle is called REM Stage 4. The first REM sleep stage lasts around 10 minutes and usually happens after having been asleep at least 90 minutes. Your eyes move rapidly in all directions during REM sleep, almost as though you are watching a movie. Typically, REM stages get longer and longer as the night goes by. Dreams (and night- mares) usually happen during the last REM stage, which can last an hour and is the deepest. This stage is also known as “paradoxical sleep.” One reason for this: Even though your brain is quite active during the stage, most of your muscles are paralyzed (Chieh, 2015).

The two main types of sleep disorders are the dyssomnias (irregularities or abnormalities in the amount, quality, or timing of sleep) and the parasomnias (sleep disturbances that result from unusual or abnormal events that occur when one is asleep, typically during the night). Psychological factors can play an important role in these disorders. Parasomnias can occur during both REM and NREM sleep. Somnambulism (sleepwalking) and enuresis (bedwetting) occur during the REM stage. We will describe the major sleep-wake disorders in the next two sections.

7.2 Dyssomnias Dyssomnias are disorders that affect the initiation or maintenance of sleep, which includes nighttime wakefulness, or excessive sleepiness. They include insomnia disorder, hyper- somnolence disorder, narcolepsy, breathing-related sleep disorders, and circadian rhythm sleep-wake-disorders.

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Insomnia Disorder Insomnia involves a disturbance in the amount, quality, or timing of sleep that occurs at least three nights per week for at least 3 months (American Psychiatric Association [APA], 2013). The most com- mon sleep-wake disorder is insomnia, called insomnia disorder in the DSM–5. Insomnia disorder is characterized by difficulty fall- ing asleep, maintaining sleep, or not feel- ing rested after normal amounts of sleep, occurring at least three nights per week for at least three months (American Psy- chiatric Association [APA], 2013). Difficulty maintaining sleep is defined in the DSM–5 as having frequent awakenings or problems returning to sleep after awakening. Overall, about one third of all adults report some symptoms of insomnia, and about 6% to 10% meet the diagnostic criteria for insomnia disorder (APA, 2013; Morin & Jarrin, 2013). The National Sleep Foundation estimates that almost 50% of the U.S. population experiences some symp- toms of insomnia during a given year (Morin & Jarrin, 2013). Typically these individuals go through the day quite sleepy and may have difficulty performing tasks, especially those that require memory and recall. This can also be dangerous as individuals may get sleepy while driving. Insomnia might be a result of the individual being under too much stress and being unable to cope, or perhaps being depressed or anxious. Insomnia can occur only on some nights but not others, or it can have a more chronic pattern, lasting weeks to many months, or even lasting a lifetime after onset.

Hypersomnolence Disorder (Hypersomnia) Hypersomnolence disorder is characterized by excessive sleepiness even though the indi- vidual may have slept at least seven hours (this qualifies as a lot of sleep for many people these days). If a person has slept for more than nine hours per day and does not feel refreshed, this qualifies as hypersomnolence. To qualify for the diagnosis, this problem must occur at least three times a week for at least three months. Typically, the individual will have difficulty getting out of bed or may take frequent daily naps. Unlike insomnia, which occurs twice as often in women (Pallesen, Sivertsten, Nordhus, & Bjorvatn, 2014; Taylor, Bramoweth, Grieser, Tatum, & Roane, 2013), hypersomnolence occurs more frequently in men (Billiard & Sonka, 2016).

Narcolepsy What if an individual quickly and unexpectedly falls asleep and goes directly into REM sleep? Narcolepsy is marked by sudden and repeated “attacks” of REM, or dream-state, sleep that may be accompanied by a brief loss of muscle tone, called cataplexy. The individual might fall asleep during a conversation or an important presentation, or might fall asleep without

OcusFocus/iStock/Thinkstock Insomnia affects nearly 50% of the U.S. population every year.

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warning while driving. Like the other dyssomnias already discussed, the individual must have, minimally, episodes three times per week for at least three months. Narcolepsy tends to be rare, affecting about 0.02% to 0.04% of the population (APA, 2013; Partinen et al., 2014). It seems that the sudden REM sleep attacks may be set off by strong emotional events such as extreme excitation, happiness, or anger. In addition, it is now known that narcolepsy is caused by an orexin (hypocretin) deficiency (APA, 2013). Orexin, also called hypocretin, is a neurotransmitter that regulates and is involved with arousal, wakefulness, and appetite. The most common form of narcolepsy, involving cataplexy, is caused by a lack of hypocretin in the brain due to destruction of the cells that produce it.

Breathing-Related Sleep Disorders Breathing-related sleep disorders are caused by sleep-related breathing difficulties that lead to excessive sleepiness or insomnia. Individuals who suffer from these disorders have interrupted sleep many times during the night and do not feel rested even when they get more than the typical amount of sleep (eight hours). These disorders are subdivided into obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. In obstructive sleep apnea hypopnea, the individual may stop breathing for as long as 30 sec- onds many times during the night, with minimally five obstructive apneas or hypopneas per hour of sleep. This may occur hundreds of times during the night, but the victim is unaware that it is occurring. Typically the individual is significantly overweight and will be a loud snorer. Obstructive sleep apnea hypopnea is associated with obesity, or being minimally 30 pounds overweight, as defined by the National Institutes of Health (Drager, Toreiro, Polotsky, & Lorenzi-Filbo, 2013), and may also be associated with increasing age (Franklin & Lindberg, 2015). Obstructive sleep apnea hypopnea can also be associated with trauma (Tamanna, Parker, Lyons, & Ullah, 2014), and it can lead to increased blood pressure and may lead to a stroke. Typically, this disorder is more common in males (Peppard et al., 2013).

Central sleep apnea is the occurrence of at least five central apneas per hour of sleep. It needs to be diagnosed via polysomnography. Polysomnography, also called a sleep study, records the individual’s brain waves, blood oxygen level, heart rate and breathing, as well as eye and leg movements. Polysomnography usually is done at a sleep disorders unit within a hospital or at a sleep center. Typically this is done at night so that the test can record the individual’s nighttime sleep patterns, but it can be performed during the day to accommodate those who work at night. An important function of this test is that it can be used to help adjust the treatment plan for an individual who has already been diagnosed with a sleep disorder (Mayo Clinic, 2017).

Finally, in sleep-related hypoventilation, which also must be diagnosed via polysomnography, the individual has decreased respiration while asleep, as demonstrated by elevated carbon dioxide levels (APA, 2013).

Circadian Rhythm Sleep-Wake-Disorders Circadian rhythm sleep-wake disorders refers to a series of sleep-wake problems in which individuals have difficulty sleeping at the times required for work, school, or other aspect of their lives. Typically this occurs when individuals do shift work; they may work two normal

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days in a row, then work three days during the night (Wright, Bogan, & Wyatt, 2013). The sleep disturbance leads to excessive sleepiness, insomnia, or both (APA, 2013). One easy way to treat this disorder, at least in theory, is to encourage the individual to get a job that has consistent working hours.

Etiology Insomnia disorder can have a variety of causes. First, people who have insomnia disorder may not become sleepy until much later at night because their body temperature doesn’t drop enough for them to fall asleep (Miller et al., 2015). Drug and alcohol usage can also contribute to insomnia disorder, as can changes in light, noise, or temperature. Psychological factors can also play a role, specifically stressful events occurring during the day (LeBlanc et al., 2007). Individuals may also misperceive how much sleep they need. In addition, they may not fully appreciate how disruptive interrupted sleep is. Insomnia disorder can also be a learned behavior. For example, the individual may associate the bed and bedroom with nega- tive thoughts or feelings related to frustrations falling asleep; therefore, bedtime sets off anxi- ety reactions (Stepanski, 2006).

Breathing-related sleep disorders can also contribute to insomnia disorder. Another etiologi- cal factor may be our always-on world—when most of us spend large amounts of time using smartphones and other electronic devices.

One interesting causal factor can be daytime naps—a common way that people try to make up for lost sleep at night. These naps can interrupt sleep the next night as the body’s natu- ral rhythms are upset. In addition, a person may think that daytime naps are a good way to compensate for lost sleep and so may anticipate the naps and, subsequently, be unable to fall asleep or have sleep disruptions at night.

Some of the sleep-wake disorders run in families, which is not a causal factor, as such, but might offer a research direction in the future (Gehrman, Keenan, Byrne, & Pack, 2015). In fact, some research has shown that 39% of people who had hypersomnolence disorder had a fam- ily history of it (Guilleminault & Pelayo, 2000). Narcolepsy may also run in families (Ohayon, 2016).

Treatment The most commonly used medical treatments for sleep-wake disorders that include insom- nia involve prescribing medications, specifically the benzodiazepines or related medica- tions. These medications include zolpidem (Ambien) and zaleplon (Sonata), two examples of short-acting drugs. Longer-lasting drugs include flurazepam (Dalmane), a benzodiazepine. Short-acting drugs are often preferred as they will have stopped working by morning and will not produce daytime drowsiness. These drugs do have negative effects though. Benzo- diazepines can cause excessive sleepiness and can lead the individual to become dependent on them. They are also designed for short-term use; long-term use can lead to dependence. Ambien, in particular, has been documented to cause sleepwalking-related problems in some people (Pagel, 2014), and nocturnal eating episodes in others (Pagel, 2014; Paulke, Wunder, & Toennes, 2015).

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Section 7.3 Parasomnias

Stimulants such as amphetamine or Ritalin are often prescribed for narcolepsy or hyper- somnolence disorder (Lopez, Arnulf, Drouot, Lecendreux, & Dauvilliers, 2017). For breath- ing-related sleep disorders, such as obstructive sleep apnea hypopnea, weight loss is often strongly recommended, but individuals given this advice are typically unsuccessful at con- quering their disorder because they often fail to lose weight or maintain weight loss (Sanders & Givelber, 2006). Mechanical devices to improve breathing during sleep, or to reposition the tongue or jaw during sleep, have also been tried, again typically with little success because of the discomfort these methods produce. One assistive mechanical device, which is quite cum- bersome, is called a continuous positive airway pressure (CPAP) machine. A CPAP machine delivers just enough air pressure to a mask to keep the upper airway passages open while the user is asleep, thus assisting breathing and making sleep apnea and poor sleep less likely. This can also be used to prevent very loud snoring, a result of sleep apnea as well as of being morbidly obese (Qaseem, Barry, Denberg, Owens, & Shekelle, 2013).

Simple environmental treatments (altering the environment to make changes in the individu- al’s behaviors) for sleep disorders include making bedtimes several hours later than normal and using bright light to help fool the brain into thinking it’s earlier than normal, known as phototherapy (Dagan, Borodkin, & Ayalon, 2006).

Relaxation techniques, described in Chapter 3, have been used to successfully treat insomnia disorder (Zacharie, Lyby, Ritterband, & O’Toole, 2016). Stimulus control techniques have also been used with greater success in treating insomnia disorder (Harvey et al., 2014). In this tech- nique, the individual is asked to use the bed for only two things: sleep and sex. This, of course, is easier said than done, as many people read, watch television, and also eat in bed. In effect, we ask the individual to redefine the purpose of the bed and the bedroom. Our constantly being connected to smartphones or tablets can also be a problem, especially before bedtime. Studies have shown that the light from screens in the evening alters sleepiness and alertness, and suppresses melatonin levels (Chang, Aeschbach, Duffy, & Czeisler, 2015). Reducing time spent using these lighted screens before bedtime might help decrease insomnia.

Finally, establishing a good sleep hygiene program, taking steps during the day and before bedtime to ensure a good night’s sleep, is also effective. Avoiding caffeine and nicotine well before bedtime, setting a regular bedtime for each night, and making sure the bedroom is the proper temperature each night are some of the preventive measures that seem to be effective (Irish, Kline, Gunn, Buysse, & Hall, 2015).

7.3 Parasomnias The DSM–5 parasomnias include non–rapid eye movement sleep arousal disorders (sleep ter- ror and sleepwalking types) and nightmare disorder.

Non–Rapid Eye Movement Sleep Arousal Disorders, Sleep Terror Type Non-rapid eye movement sleep arousal disorder, sleep terror type is not related to nightmares (dreams arousing feelings of intense fear, horror, and distress) as sleep terror

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disorder occurs during NREM sleep, whereas night- mares occur during REM sleep. Typically sleep ter- rors affect children and cause them to awaken with a frighteningly loud scream. The child will have a rapid heart rate, be very upset, and often be sweat- ing profusely. Typically, sleep terrors appear in children, disappear in adolescence, and affect up to 6% of children at one time or another (APA, 2013). Oddly enough, children do not recall sleep terrors (Tinuper, Bisuli, & Provini, 2012). Sleep terrors affect about 2% to 4% of adults (Carrillo-Solano, Leu-Semenescu, Golmard, Groos, & Arnulf, 2016).

Non–Rapid Eye Movement Sleep Arousal Disorders, Sleepwalking Type Non-rapid eye movement sleep arousal disor- ders, sleepwalking type (sometimes called som- nambulism when it recurs) is primarily a childhood disorder that, surprisingly to most people, occurs during NREM sleep (APA, 2013). It typically occurs during the first few hours of sleep (the first third of sleep). Affected individuals will usually leave their

beds repeatedly during the night and walk around without being conscious of doing so or being able to recall doing so later, once awake. It is not dangerous to awaken a sleepwalker, but if left alone, the individual will typically return to bed. Statistics vary, but anywhere from 2% to 5% of children have repeated episodes (APA, 2013) and up to 40% of children may have at least one episode (APA, 2013). Stress and extreme fatigue may be related to sleep- walking (APA, 2013). Sleepwalking usually ends by the time a child reaches age 15. Like night terrors, this disorder affects about 2% to 4% of adults (Carrillo-Solano et al., 2016).

Nightmare Disorder We mentioned nightmares earlier, but when do nightmares become nightmare disorder? According to the DSM–5, the extended and unfortunately well-remembered dreams of night- mare disorder usually have themes of “avoiding threats to survival, security, and physical integrity” and “generally occur during the second half of a major sleep episode” (APA, 2013, p. 404). Typically the individual will awaken rapidly and do so repeatedly following a night- mare. Nightmare disorder tends to affect women slightly more so than men (Sandman et al., 2013).

Etiology and Treatment We still know little about the etiology and treatment of parasomnias (Owens & Mohan, 2016; Tinuper et al., 2012), and currently there are few recommended treatments for these

Creatas Images/Creatas/Thinkstock Contrary to popular myth, it is not usually considered dangerous to awaken someone who is sleepwalking.

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Section 7.4 Feeding Disorders

disorders. One efficacious method used to treat and eliminate sleep terrors in children is scheduled awakenings, in which the parent is told to wake the child about 15 to 20 minutes before each sleep terror episode is expected to begin (Kuhn & Elliot, 2003; Mindell, Kuhn, Lewin, Meltzer, & Sadehet, 2006). The same method can be used with adults. Typically adults can go to a sleep disorders clinic, where their sleep patterns and behaviors can be observed and measured (for example, with an electroencephalograph, or EEG). Behavior modification techniques can be used, as well as psychotherapy to see if the nightmares have recurring themes. An efficacious method is for someone observing an individual having nightmares or night terrors to take notes and record the themes, if the individual can recall the nightmares or night terrors on waking (Owens & Mohan, 2016).

In sum, we still do not know a lot about sleep disorders, but we do know that many indi- viduals in the United States do not get enough sleep, making problems more likely to occur. Research continues into these somewhat puzzling disorders.

7.4 Feeding Disorders Like all animals, humans must eat regularly and properly in order to stay physically and psy- chologically healthy, to survive, and to thrive. Individuals who have a feeding or an eating disorder may eat too much in too short a timeframe, or they may eat too little and thus lose a significant amount of weight, becoming dangerously underweight for their height or age. (See the accompanying Highlight for a look at eating disorders in a modern context.) Alternatively, they may eat nonnutritive or nonfood substances, such as wood shavings or lead paint chips.

Highlight: Eating Disorders and the Internet

The possibilities are quite strong that you have heard of pro-anorexia (pro-ana) and pro- bulimia (pro-mia) websites. An Internet search will reveal a lot of them. What are these sites about? Generally speaking, they promote anorexia nervosa and bulimia nervosa as lifestyle choices as well as diet options. The creators of these sites see nothing wrong with these behaviors. For example, a 16-year-old blogger shared this piece of advice: “Wear a rubber band around your wrist and snap it when you want to eat. Food = pain.” Most people would agree that this statement promotes unhealthy, potentially lethal behavior. But what about the women who think this is normal? How can we hope to help them and provide treatment to them if they see these kinds of statements online, promoted as normalcy? These sites also equate amenorrhea as a measure of successful weight loss, whereas the DSM–IV–TR saw this as a diagnostic criterion for anorexia nervosa. Clearly there are different perspectives here.

Pro-mia websites are the same, except they focus on bulimia nervosa, not anorexia nervosa. Many people are not aware that such sites exist, yet once they view them, for the most part, they become disturbed by what they read. In the United States, freedom of speech is a fundamental right, but perhaps the creators of these kinds of sites should think about the consequences of the behaviors they are promoting. Some social media sites have attempted to ban or restrict such sites, but they usually just pop up elsewhere. What is your perspective?

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Pica Pica is an unusual eating disorder that occurs in people across socioeconomic groups, ages, and genders (Stiegler, 2005), although it may be more prevalent among women, children, and those of lower socioeconomic status (Delaney et al., 2015; Kelly, Shank, Bakalar, & Tanofsky- Kraff, 2014). The name pica comes from the Latin word for “magpie,” a bird known to eat practically anything. This is precisely the problem in pica. People with this disorder have been known to eat dirt, laundry starch, chalk, buttons, paper, cigarette butts, matches, sand, soap, toothpaste, and many other supposedly inedible substances. The main DSM–5 diagnostic cri- teria for pica appear in Table 7.1. Note that it is important to consider cultural practices when making this diagnosis. Members of cultures that sanction the consumption of odd substances, such as clay, are not suffering from a psychological disorder.

The prevalence and cause of pica are unknown. Psychological theories tend to be vague (for example, “fixation at the oral stage of development”). Physiological explanations are not much better. Most are based on the idea that diet deficiencies (too little iron or zinc, for example) cause a craving for anything containing these missing minerals. Yet most of the items craved by people with pica do not actually supply the missing minerals.

Rumination Disorder and Avoidant/Restrictive Food Intake Feeding Disorder The DSM–5 includes two other feeding disorders usually found in infants or young children: rumination disorder and avoidant/restrictive food intake feeding disorder. Rumination dis- order is marked by regurgitation of food, whereas avoidant/restrictive disorder of infancy is manifested by inadequate eating. Both disorders are diagnosed only when there is no clear medical condition causing the symptoms, and little is known about the prevalence or etiology of either one (APA, 2013; Delaney et al., 2015).

Table 7.1 DSM–5 diagnostic criteria for pica

A. Persistent eating of nonnutritive, nonfood substances over a period of at least one month. B. The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the

individual. C. The eating behavior is not part of a culturally supported or socially normative practice. D. If the eating behavior occurs in the context of another mental disorder (e.g., intellectual disability

[intellectual developmental disorder], autism spectrum disorder, schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to warrant additional clinical attention.

Specify if: In remission: After full criteria for pica were previously met, the criteria have not been met for a sustained period of time.

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Section 7.5 Eating Disorders

7.5 Eating Disorders What do Lady Gaga, Demi Lovato, Paula Abdul, Fiona Apple, Oprah, and the late Princess Diana have in common? All of these women had an eating disorder, in most cases bulimia nervosa (described later in this section). To their credit, many if not most of them have been or were open about their struggles.

Eating disorders refer to extreme distur- bances in eating behavior. Two core features of eating disorders are an obsession with losing weight and a morbid fear of gaining weight. The hallmark characteristic of eat- ing disorders is the desire for, and perhaps obsession with, getting thin or remaining thin. In this section we will examine the two most common eating disorders, anorexia nervosa and bulimia nervosa. Anorexia nervosa is marked by an obsessive and irrational fear of gain- ing weight, with a resultant major reduction in food intake (known as restriction), so much so that the individual loses a significant amount of body weight (APA, 2013). Those suffering from bulimia nervosa may be obsessed with maintaining weight by binging (out-of-control eating) and then using an inappropriate compensatory behavior (such as fasting or using laxatives) to prevent weight gain (APA, 2013).

We will also briefly examine binge-eating disorder (BED), which was first identified in the 1990s and was under further review in the DSM–IV–TR. This disorder has now been included as a diagnosis in the DSM–5 (APA, 2013). Individuals with BED experience marked distress as a result of their binging. However, binging is not then followed by inappropriate compensa- tory behaviors, defined as purging or restriction (that is, self-starvation) as it is with other eating disorders. (See the comparison of eating disorders in Figure 7.1).

In this chapter, we frequently focus on women when discussing anorexia nervosa and buli- mia nervosa. We do so simply because these disorders overwhelmingly affect females; per- haps as many as 90% to 95% of individuals with anorexia nervosa and bulimia nervosa are female (Smink, van Hoeken, Oldehinkel, & Hoek, 2014). Data point to the lifetime prevalence of anorexia nervosa as ranging anywhere from 0.5% to 2% of the female population in West- ern countries; some researchers estimate that the prevalence is closer to 0.3% (Litmanen, Fröjd, Marttunen, Isomaa, & Kaltiala-Heino, 2017). Another study suggests that as many as 5% of women develop bulimia from ages 14 to 15 (Kjelsas, Bjornstrom, & Gotestam, 2004), and a more recent estimate puts the rate of bulimia in men at about one-tenth the rate in women (APA, 2013). This discrepancy leads researchers to hypothesize that gender and/or gender roles may somehow be involved in the development of eating disorders. It has also been hypothesized that hormones and estrogen levels may be involved (Getzfeld, 2006).

Anna Celadina/Hemera/Thinkstock Eating disorders are often caused by an obsessive or irrational fear of gaining weight.

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Figure 7.1: Similarities and differences among eating disorders

Source: Adapted from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Table 12.6, p. 543.

Has missed at least three menstrual periods Obsessed with food and odd eating rituals Binges Exercises excessively Gains weight Expresses dissatisfaction with appearance Considers binging beyond control Vomits or uses drugs to purge calories Disappears into bathroom for long periods (to purge)

Weight less than 85% of expected weight Considers self fat even though severely underweight

*Binge-eating/purging subtype

Symptom Anorexia nervosa

Bulimia nervosa

Binge-eating disorder

X* X

X X X

Eating disorders did not attract much research until the 1960s (Fairburn & Brownell, 2002; Striegel-Moore & Smolak, 2001). More important, anorexia nervosa and bulimia nervosa did not appear in the DSM until the DSM–III (APA, 1980). Due to the late acknowledgment of eat- ing disorders in the research community, the scientific and research information that we have on bulimia and anorexia nervosa is somewhat limited. It is remarkable that we know as much as we do about these disorders given the relatively short period of time in which they have been scientifically investigated. Before we examine anorexia nervosa, let’s meet Paula Ames in Part 1 of her case study.

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Section 7.5 Eating Disorders

The Case of Paula Ames: Part 1

Paula, a 31-year-old single Caucasian female, is an undergraduate student in liberal arts at a major university. Paula’s height is approximately 5’6” and she was initially reluctant to share her weight with her psychologist. Paula works as a waitress full time in order to pay her tuition and to make ends meet. Paula was pleasant during the sessions but often seemed rather tense and on edge. She kept checking her watch, and she wore long sleeves even though it was summer.

Excerpt From Transcript of Treatment Session Conducted by Dr. Brian Philipps With Paula Ames Brian Philipps, Ph.D. Psychologist

Transcript of Treatment Session: Paula Ames

Client: Paula Ames

Therapist: Dr. Brian Philipps

DR. PHILIPPS: What brings you to therapy today, Paula?

PAULA: I need to finally shut certain people up, especially my Mom and my fiancé. They have really been driving me crazy about my eating. It’s not like I do anything odd; most women diet before their wedding. My wedding is in a few months, and I need to fit into my dress. I need to lose a few pounds, but I do like my food. I’m also not the biggest fan of crowds . . . I don’t do well in social situations . . . everyone always seems to be staring at me, so we are trying to keep the number of guests down.

DR. PHILIPPS: I would like to try and understand why your family and future husband might, as you say, be concerned about your eating. Would you be able to describe your diet for me?

PAULA: Well, I’m tall—5’6”—and I weigh . . . do you need to know exactly, because I can tell you exactly. Like, I know how to calculate accurately as I bought a very expensive scale. I weigh 92 pounds and that is too much. I want to be a beautiful bride, so I need to lose about maybe 5 more pounds to get into the best dress I can afford. This is my day, my fairytale. Cinderella wasn’t fat like I am. I look at my arms and see the flesh hanging off . . . blech.

DR. PHILIPPS: I see. And would you be able to describe your eating behaviors?

PAULA: I eat . . . What is it with you people? Food is not a problem for me. I told you I need to get to the proper size before my wedding. I’m a flabby Patty right now, and a flabby bride won’t do. My fiancé will leave me at the altar if I don’t lose a bit more.

DR. PHILIPPS: Could you perhaps be more specific about your eating behaviors? For example, what do your meals look like on a daily basis? How would you say you manage your weight?

PAULA: Manage my weight? Not real well as you can see. I eat normal meals, cereal at breakfast, sandwich for lunch, yogurt for dinner, maybe iceberg lettuce. Always drink water, as that’s the healthiest, or tea plain. No coffee or coffee specialty drinks. I need to keep my calories down, no more than 500 a day tops; 300 is much better, of course.* Sometimes I exercise to keep the weight off or to lose the weight. But I can handle food; it’s not a weird thing for me.

See appendix for full case study.

*Note: The suggested calorie count for females is anywhere between 1,500 and 2,000 calories per day.

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Section 7.5 Eating Disorders

Anorexia Nervosa Anorexia nervosa literally means “nervous loss of appetite,” though this is misleading as the individual usually maintains an appetite. Three DSM–5 criteria need to be met for a diagnosis of anorexia nervosa.

First, individuals must refuse to maintain their minimally normal body weight for their age, sex, developmental trajectory (expected height), and physical health. This is defined as a weight that is less than that which is minimally normal (in the DSM–IV–TR this was defined as body weight less than 85% of that expected for individuals of the same age and height; APA, 2013) or for children and adolescents, a weight that is less than is minimally expected of them (APA, 2013). The “85%” criterion was removed from the DSM–5.

Second, individuals must have an intense fear of gaining weight or becoming fat, even though they are obviously at a significantly low weight (APA, 2013). This is a crippling fear, perhaps obsessive in nature, that limits the individual’s life so much that he or she becomes com- pletely focused on either not gaining any additional weight or perhaps trying to lose even more weight. Not only is there a heightened fear of weight gain, but the individual’s behavior ensures he or she will not gain weight. (See the accompanying Highlight.)

Highlight: Body Dissatisfaction

“Tell me what you don’t like about yourself ”—this question opened every episode of Nip/ Tuck, a television drama about plastic surgeons that ran from 2003 to 2010. Although the series slanted toward the bizarre, it made some important points about people and society in general. Wouldn’t every person asked this question be able to reel off a whole list of body dissatisfactions? Is there something wrong with not liking aspects of yourself ? If you look at the data, you can see that the number of plastic surgeries increased by about 4% from 2015 to 2016 (from 1,715,224 total procedures to 1,780,987; American Society of Plastic Surgeons, 2017). The top three procedures were breast augmentation, liposuction, and nose reshaping (rhinoplasty). Evidently a large number of people in the United States do not like aspects of themselves.

Yet body dissatisfaction, paired with obsessions over celebrities such as the Kardashians, Taylor Swift, and so many others, can lead to devastating outcomes. Seeking surgery after surgery in the pursuit of mythical perfection—or developing unhealthy eating habits that can lead to a full-blown eating disorder—carries grave risks. Perhaps helping professionals can promote the concept that you are okay just the way you are, and that it’s okay to be dissatisfied with a feature or two. It takes all kinds to make up the world, and not everyone can look alike. Maybe such an approach could lead to a decrease in eating disorders—and in unnecessary plastic surgeries as well.

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The third criterion is the denial of the seriousness of the low body weight or a disturbance in how the individual experiences or perceives her or his weight or shape (APA, 2013). Individu- als will usually see themselves as quite obese even though it is obvious to everyone else that they are seriously malnourished (Farrell, Lee, & Shafran, 2005). Denial appears to be a key component of eating disorders. This can be denial of the individual’s actual shape or denial of the seriousness of the problem.

The DSM–5 lists two subtypes of anorexia nervosa. The main difference between these two subtypes involves how individuals with anorexia nervosa manage to maintain their abnor- mally low weight, or how they continue to lose weight. The restricting type is characterized by individuals being meticulous, perhaps obsessive, about how much food they eat at a given time, and what their caloric intake is at each meal or on a daily basis. Typically, these individu- als will first cut out sweets and other foods perceived as “fattening” (APA, 2013). Individuals do not regularly engage in binge-eating or purging behavior (APA, 2013). The binge-eating/ purging type is characterized by individuals regularly engaging in binge-eating or purging behavior such as self-induced vomiting or the misuse of laxatives, diuretics, or enemas (APA, 2013). The individuals feel like they cannot control the binging behavior. Binges are typically smaller than those seen in individuals with bulimia, and purging happens more often than it does with bulimia, typically after every meal (Agras, 1987). It has been estimated that about 50% of all individuals with anorexia nervosa binge and purge. Note also that for anorexia to be diagnosed with either subtype, the symptoms must be active for a period of at least three months (APA, 2013; Smink et al., 2014).

Eating disorders, particularly anorexia nervosa, are the most lethal of all of the mental dis- orders, including unipolar depression (Franko et al., 2013). In the past, some research dem- onstrated that approximately 20% of individuals with anorexia nervosa died from medical complications related to their disorder; at least 50% of these were suicides (Chavez & Insel, 2007; Mehler & Brown, 2014). Other studies state that the death rate from anorexia ner- vosa is approximately 2% to 6% (Kask et al., 2016; Suokas et al., 2013), although a certain percentage of those deaths were due to suicide. Getzfeld (1999) hypothesized that females with anorexia nervosa may be engaging in a form of suicide, slowly disappearing and wast- ing away. Psychologically, they are detached, focused solely on their body image and their weight, or lack thereof, and physically detaching themselves from life.

Bulimia Nervosa Whereas anorexia nervosa affects between 0.5% and 2% of all women in Western- ized countries (Ekern, 2014; Smink et al., 2014; Stice, Burger, & Yokum, 2013), buli- mia nervosa, literally “hunger of an ox,” affects between 2% and 5% of the popu- lation (Ekern, 2014). Bulimia nervosa is characterized by the individual eating an unusually large amount of food at a single sitting and then using inappropriate com- pensatory behavior(s) to rid the body of the excess calories. An individual suffering from

vadimguzhva/iStock/Thinkstock People with the restricting type of anorexia nervosa become meticulous about the amount of food they eat on a daily basis.

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bulimia nervosa will often binge on 3,000 to as many as 6,000 calories in a single sitting and then compensate by purging through vomiting or using laxatives, or by fasting (APA, 2013). Although the average calorie count for a binge, which might occur as often as 30 times per week, is about 3,400 calories, binges may reach as high as 10,000 calories. Consider that a McDonald’s Big Mac sandwich has 560 calories. A binge of approximately 3,000 calories is equivalent to eating about 5.5 Big Macs in one sitting; a binge of about 10,000 calories would be the same as consuming 18 Big Macs, also in one sitting.

Bulimia nervosa is diagnosed by using five DSM–5 criteria. First, these individuals must have recurrent episodes of binge eating (where they eat much more during a specific time period than most people would under similar circumstances [APA, 2013] and believe they have no control over this behavior). They feel that they cannot stop their eating or control what they are eating or how much they are eating.

Second, the individual must engage in recurrent inappropriate compensatory behaviors, which means they must engage in self-induced vomiting or misuse of diuretics (medications that increase urination), laxatives, or enemas. These are all examples of purging behaviors. The goal of a purge is to eliminate all of the food that was consumed during the prior binge. It is only a purge if the food is somehow forced out of the body by inappropriate compensatory behaviors. (A person who unintentionally vomits is not purging.) Inappropriate compensa- tory behaviors are behaviors designed to counterbalance and counteract the effects of the binge. They are designed to ensure that the individual with bulimia does not in fact gain any weight, but they also serve to give the individual the illusion of self-control. Their purging seems to alleviate any anxiety caused by the fear of gaining weight. Another way that the individual can eliminate the food is through fasting or exercising excessively, such as exercis- ing at least three hours a day every day, presuming that he or she is not a professional ath- lete or in training for a competition such as the Olympics (APA, 2013). Some people call this behavior “exercise bulimia nervosa.” Unfortunately, the DSM–5 does not define the terms excessively or misuse, which can be problematic as it is left up to clinicians and psychologists to interpret these terms.

Third, the binging and purging, or other inappropriate compensatory behavior, must occur on average at least once per week over a three-month period. Fourth, the individual’s self-evaluation must be unduly influenced by their body weight and shape (APA, 2013). These people place extreme and excessive emphasis on body weight and shape to the point where it seems to become an obsession. (Obsessions were discussed in Chapter 3.) In fact, only about 3% of the women with bulimia in one dated study were not obsessed (our word) with their body’s weight and shape (Garfinkel, 1992).

Stockbyte/Stockbyte/Thinkstock One way individuals with bulimia nervosa eliminate the food consumed during binging is through excessive exercise, which often means exercising several hours every day.

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Binge-Eating Disorder (BED) Binge-eating disorder (BED) involves binging episodes similar to those found in bulimia ner- vosa but without the inappropriate compensatory behaviors (for example, purging and self- starvation). In effect, the main, and some might say only, diagnostic criterion for BED is recur- rent episodes of binge eating that occur on average at least once per week for three months, identical to the first criterion for bulimia nervosa. A critical difference between BED and buli- mia nervosa is that the DSM–5 definition for BED does not include inappropriate compensa- tory behaviors being demonstrated by the individual, a criterion of bulimia nervosa (APA, 2010, 2013). In addition, BED cannot be comorbid with anorexia nervosa or bulimia nervosa (APA, 2013). The DSM–5 diagnostic criteria for BED are summarized in Table 7.3. (Which of the eating disorders do you think Paula Ames has? See Part 2 of her case in the appendix.)

The fifth DSM–5 criterion states that bulimia nervosa does not occur solely during episodes of anorexia nervosa (APA, 2013). We must be able to distinguish between bulimia nervosa and anorexia nervosa, as treatment modalities differ significantly, especially the often recom- mended and/or required medical interventions.

The DSM–5 diagnostic criteria for bulimia nervosa are summarized in Table 7.2. Table 7.2 DSM–5 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 (e.g., within any two-hour period), an amount of food that is definitely

larger than most people would eat during a similar period of time and under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or

control what or how much one is eating). B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain (e.g., self-induced vomit-

ing; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise). C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week

for three months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Table 7.3 DSM–5 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 (for example, within any two-hour period), an amount of food

that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

2. A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating).

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 being embarrassed by how much one is eating. 5. Feeling disgusted with oneself, depressed, or very guilty after overeating.

C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for three months E. The binge eating is not associated with the recurrent use of inappropriate compensatory behaviors as in

bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Source: APA (2013, p. 350).

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Etiologies of Eating Disorders Researchers have uncovered several factors they believe influence the emergence of eating disorders in general, or anorexia nervosa or bulimia nervosa specifically, and developed theo- ries to explain these factors.

Sociocultural Factors Unlike many of the disorders in this book, both bulimia nervosa and anorexia nervosa seem to occur most often within specific Westernized countries, specific age groups, specific social classes, and most commonly in females.

Eating disorders may now be crossing racial boundaries (Perez, Ohrt, & Hoek, 2016; Solmi, Hotopf, Hatch, Treasure, & Micali, 2016). However, eating disorders have been viewed as by- products of Western cultures where the media—including television, Internet, and movies— “shape” people’s opinions of how a healthy body should appear, which, in this case, means thin (Ferguson, Muñoz, Garza, & Galindo, 2013). Anorexia nervosa is more common in industrial- ized societies, especially in those societies where Western media influence is pronounced, and where female thinness is seen as an ideal (Pike, Hoek, & Dunne, 2014). In nonindustrial- ized societies, or in societies where Western influence is minimal, a more rounded figure is preferred. In addition, eating disorders manifest themselves during adolescence and young adulthood for a simple reason: Society expects females to be thin. These women may be inter- nalizing this concept (Hoek, 2002; Hsu, 1990).

What does internalizing “thin is in” mean? What this means is that some women (and men) appear to be more vulnerable to mass media’s ideas of the ideal body shape and size, whereas others are less so. For men, this would be a shape that is lean yet muscular, with the so-called “six-pack” abdominal muscles made famous by Mike “The Situation” Sorrentino on the TV show The Jersey Shore or Zac Efron in the movie Baywatch (2017). For women, this would be a body that either has little body fat or else has impossible curves like Barbie, even in her newer, “more accurate” version. An individual’s ability to avoid developing a negative body image and negative self-statements, in addition to being able to avoid the pressure to either remain thin or to lose more weight, seems to be related to media exposure, how well the individual can handle environmental stressors, and the quality of the individual’s support systems (Stice, Schupak-Neuberg, Shaw, & Stein, 1994; Stice, Spangler, & Agras, 2001). (See the accompanying Highlight.)

Psychological Factors Even though familial and sociocultural factors surely play some role in the development of eating disorders, a number of psychological factors have also been implicated in their etiolo- gies. These include individuals striving for some kind of control in their lives, interoceptive awareness, separation problems, and body dissatisfaction.

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Striving for Control One trait that appears to be common among individuals with anorexia nervosa is that they tend to be perfectionists and have obsessive-compulsive tendencies. These in- dividuals struggle for control and perfection in every part of their lives and, therefore, also with their bodies. The lack of eating can perhaps be viewed as a way to gain con- trol over their lives and as a way to develop a sense of independence—an idea posited by Hilda Bruch (1973). Individuals may feel that their weight, and thus their appearance, is the only thing that they can control with- out parental or other outside influence or interference; anything less than perfection is considered to be a failure, especially by individuals with anorexia nervosa (Bruch, 1973; Pearlman, 2005).

Highlight: The Media, Anorexia Nervosa, and Bulimia Nervosa

In 2016 Sports Illustrated chose three women to be cover models for its annual swimsuit issue, which many people argue promotes subtle sexuality and female objectification, and not swimsuits. Suppose you received all three issues and you were an adolescent female. You would soon see that Haley Clauson, a “supermodel,” is topless and is quite thin. Ronda Rousey, a mixed martial arts former champion, appears in body paint, totally nude underneath. Ashley Graham, a “plus sized” supermodel, appears in a two-piece swimsuit. Why is Graham, who by standard modeling criteria is overweight and perhaps obese, wearing a two-piece swimsuit, while the others, who are a lot thinner, are not? What does this convey about body image as well as what is considered normal? What would your reactions be if Graham were topless or nude, with her body parts tastefully covered? Could she appear in ESPN’s The Body Issue, where famous athletes from all sports appear nude? Which woman would a teenager be most likely to identify with? The media promote certain body types and shapes as being aesthetic, sexy, and “normal,” while promoting others stereotypically. How often do you see someone who has curves like Graham playing a romantic role, or a lead, for example? In many shows and movies, such actresses usually portray funny, sarcastic supporting characters. Why can’t they be considered “sexy” or their bodies be seen as normal?

urfinguss/iStock/Thinkstock For many sufferers of anorexia nervosa, a lack of eating feels like a way of taking control over their lives and their bodies.

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Interoceptive Awareness Interoceptive awareness refers to an individual’s awareness of internal cues, including emo- tional states and hunger (Khalsa et al., 2015; Lavender et al., 2014). Individuals with anorexia nervosa may be more in touch with their appearance than with the fact that they feel sad, angry, happy, or disgusted. Because of this, they don’t recognize certain internal cues, such as hunger pangs. Researchers have found that some women without a high level of interoceptive awareness cannot recognize when they are sated (Viken, Treat, Nosofsky, McFall, & Palmeri, 2002). Earlier research noted that a lack of interoceptive awareness was able to predict the development of eating disorders as much as two years into the future (Leon, Fulkerson, Perry, & Early-Zald, 1995).

Body Dissatisfaction Body dissatisfaction is a key factor in both bulimia nervosa and anorexia nervosa. In both cases, the disorder is caused and perpetuated by the individuals wanting to change their bod- ies. However, individuals with anorexia nervosa are much more concerned with their appear- ance and are totally dissatisfied with their body shape, to the point of evidencing pathology. In other words, these individuals will continue to starve themselves even when their weight is dangerously low “just to lose a bit more” and to appear ever thinner. Individuals with bulimia, who may starve themselves as a method of staving off weight gain, will be of a normal weight or slightly overweight. They tend to be more concerned with pleasing others, are often more concerned with being attractive to others, and are more likely than individuals with anorexia nervosa to have sexual relationships (Striegel-Moore, Silberstein, & Rodin, 1993). Cultural influences in Western societies contribute to this body dissatisfaction by placing a very high value on a reed-thin body (Culbert, Racine, & Klump, 2015).

Biological Factors Like many of the psychological disorders, eating disorders seem to run in families and seem to have a genetic component (Culbert et al., 2015; Starr & Kreipe, 2014). In addition, low levels of serotonin activity have been linked to bulimia nervosa (e.g., Phillips et al., 2014; Starr & Kreipe, 2014), especially to binge eating of carbohydrates (Kaye et al., 2012). Sero- tonin is a neurotransmitter that is involved with information processing and coordination of motor skills, specifically movement. It is also involved with inhibition and restraint and helps to regulate aggression, sexual behaviors, and eating, which would include binging and purging. Irregular serotonin levels have been directly implicated in the etiology of unipolar depression (Gryglewski, Lanzenberger, Kranz, & Cumming, 2014) and in obsessive-compul- sive disorder (Lissemore et al., 2014), both of which are sometimes comorbid with eating disorders (Cederlöf et al., 2015; Godart et al., 2015), although it is unclear which condition manifests first (Getzfeld, 1992). This link between eating disorders and unipolar depression and obsessive-compulsive disorder can be substantiated by the fact that antidepressants that work to increase serotonin activity in the brain will, in many instances, reduce and/or elimi- nate bulimic symptoms (Milano et al., 2013).

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Some researchers believe that people with eating disorders have serotonin levels that are too high, and that this irregularity is present at birth (Kaye et al., 2005). By self-starvation or purging, the individual is, perhaps unconsciously, attempting to reduce these unusually high serotonin levels (Kaye et al., 2005).

The Psychoanalytic Perspective Psychoanalysts believe that people with bulimia nervosa see their families as rejecting of them, and they often engage in arguments and conflicts, whereas individuals with anorexia nervosa may see their families as being overly close (Fornari et al., 1999). Bruch (2001), whose work in studying and treating eating disorders was groundbreaking, noted that a dys- functional relationship between the mother and her child led to, among other things, a poor sense of independence and control, which eventually led to the child manifesting an eating disorder. She called this an ego deficiency in the child.

Bruch saw a dichotomy in how parents respond to their child’s needs. Effective parents feed their children when they are hungry, and comfort them when they are frightened, sad, or in pain. By contrast, ineffective parents do not properly attend to their children’s needs. For example, they might feel or determine that the child is hungry or in need of comforting while misinterpreting the child’s actual condition. They might feed the child when the child is in pain and needs comforting, or comfort the child instead of feeding him or her when the child is hungry. According to Bruch (1973), children raised in this fashion may be unaware of or confused about their internal needs (hunger, pain, and so on), leading to their being unable to correctly recognize and identify their emotions. Once children reach adolescence, their desire to become more independent understandably, and predictably, increases, but they feel as though they are unable to do so. In effect, they demonstrate reaction formation: Because they feel helpless and that they lack control, they instead do the opposite, which is they seek out excessive control over their body and eating behaviors. There is some support for this hypothesis (for example, Holtom- Viesel & Allan, 2014), as well as for Bruch’s point that individuals who have an eating disorder misperceive their internal cues (Lavender et al., 2014). Keep her points in mind, especially when we discuss treatment modalities.

The Behaviorist Perspective According to Bandura’s modeling theory (which states that a child who is interested in a model’s behavior and is able to repro- duce it will indeed do so), parents may be the cause of eating disorders in their chil- dren. Per Bandura’s theory, children whose parents are on a diet will notice how pre- occupied the parents are with their caloric intake and decide they too should get

Denver Post/Getty Images Hilde Bruch, a pioneer in the study and treat- ment of eating disorders.

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involved in this diet program. Additionally, parents may push their children to lose weight, whether to win a spot on the cheerleading team or simply to compete with the children’s thinner peers in school (Abraczinskas, Fisak, & Barnes, 2012). Recent research has also noted that mothers, fathers, and peers each played an important role in the development of girls’ bulimic symptoms by affecting their body dissatisfaction, which was related to later dieting behaviors, depressive symptoms, and bulimic symptoms (Blodgett-Salafia & Gondoli, 2010). The results suggested that peers were a stronger influence than mothers and fathers. (See Part 3 of Paula Ames’s case in the appendix.)

Treatment of Anorexia Nervosa Successful treatment for anorexia nervosa is rather limited (Hsu, 1990). In one study, approximately 10% to 20% of patients with anorexia nervosa remained at their pre- treatment weight during their posttreat- ment follow-ups (Haliburn, 2005). What this means is that many patients with anorexia nervosa do not respond well to treatment, which often includes inpatient hospitaliza- tion. For those who do initially respond to treatment, recovery may not last (Richard, Bauer, & Kordy, 2005).

Anorexia nervosa treatment includes two goals. The first, most immediate goal is to get the individual to gain back a certain amount of weight and to attempt to normal- ize her eating pattern. In life-threatening cases, this may need to occur in an inpatient setting. This type of intervention is war- ranted if patients absolutely refuse to eat or if their weight is significantly below where

it should be. This can lead to increased risk for cardiac arrest. If individuals refuse to eat, they would need to be force-fed via intravenous lines and/or via a tube down the throat. This can lead to an early treatment obstacle because the force-feeding may lead to distrust of treat- ment professionals, setting up an aversive condition. For a variety of reasons, not the least of which is to avoid setting up such a condition, treatment now typically occurs in an outpatient setting or in a day treatment hospital (see, for example, Raveneau et al., 2014).

One advantage of day treatment hospitals or, if the individual’s life is at risk, inpatient set- tings is that weight gain can be monitored carefully. The weight gain should be gradual, with a target of about two to three pounds per week, although this depends on the individual’s weight at treatment onset. In some instances, the individual might gain as much as a pound per day. There are several reasons the weight gain needs to be gradual and not sudden. Psy- chologically, rapid weight gain might scare the patient, and the patient might drop out of

Siri Stafford/Photodisc/Thinkstock Treatment for anorexia nervosa is not always successful, which can often lead to patients being hospitalized so that necessary weight gain may be carefully monitored.

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treatment, making the treatment goal act like a punishment. The APA (2000, 2013) also notes that if weight gain is rapid, the individual might suffer from constipation, abdominal pain, and bloating. The most commonly used weight restoration method is usually called a nutritional rehabilitation program. This includes nursing care, nutritional counseling, and a high-calorie diet to help the individual get back to normal eating and to help her gain weight (Leclerc et al., 2013). Typically, the calorie count will increase gradually until it reaches approximately 3,000 calories per day (Zerbe, 2010). These programs usually last from 8 to 12 weeks.

The second goal of treatment is to work on the psychological, social, and environmental issues that either may have caused or are somehow maintaining the disorder and thus interfering with recovery. Some of these issues include working with individuals to change their dysfunc- tional body image attitudes and working on the interpersonal problems they have in their lives (with, for example, family, friends, and significant others). The issue of loss of control of one’s eating is also addressed in therapy. Treatment is typically conducted through family therapy, self-help groups, or individual therapy.

Family therapy is most successful with adolescents who have had anorexia nervosa for less than three years, that is, with an early onset and a short duration (Rutherford & Couturier, 2007). The core problem is presumed to be the parents’ disagreement with, and perhaps denial of, the adolescent’s desire for autonomy. Mealtimes and thoughts about food and weight are typically dysfunctional within the individual’s family and are focused on in treatment. Family attitudes toward body shape, as well as any underlying conflicts, will be discussed. Typically, in family therapy, the therapist will work to get the individual out of the role of being a “sick” child and will work with the parents to confront their own issues and conflicts directly with each other and not through their children (Minuchin, Rosman, & Baker, 1978). One main goal is to get the family to work as a team to address the anorexic eating behaviors and to function better as a family unit in general. Whereas some studies note that family therapy appears to be one of the more successful treatment modalities for anorexia nervosa (Dare & Eisler, 2002; Lock & le Grange, 2005), many therapists will use this modality in combination with individual and group therapy as well as self-help groups.

Cognitive-Behavioral Therapy Cognitive-behavioral therapy (CBT) is often used in conjunction with other techniques pre- viously mentioned to treat anorexia nervosa. Therapists may work with individuals to help them learn more appropriate ways to exercise control, as anorexia nervosa is often caused in part by an individual’s wanting to feel in control. The individual’s attitudes about food, eating, and weight would also be examined in therapy. Typically these individuals view food as an enemy. Therapists would work on what are called faulty cognitions, sometimes called irra- tional beliefs. These are irrational or false beliefs that result in self-defeating behavior(s) that the person demonstrates. The individual’s cognitions are so faulty that they obscure the truth; thus, the individual believes in the falsehoods. Individuals’ self-esteem ends up even more damaged and self-destructive behaviors become entrenched (see, for example, Fair- burn & Cooper, 2014; Lask & Bryant-Waugh, 2000; McFarlane, Carter, & Olmsted, 2005).

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Psychotropic Medications Many professionals agree that medications should not be used in the treatment of anorexia nervosa because they tend to be rather ineffective (Watson & Bulik, 2013). Since many of these individuals are severely underweight, potential medication side effects could be more pronounced, leading to significant complications. Being malnourished or severely under- weight can change the amount of medicine in the individual’s body. Too much or too little can be dangerous. For example, tricyclic antidepressants (TCAs) may lead to heart arrhythmias, which can lead to cardiac arrest. In fact, antidepressants, in general, seem to be ineffective in treating anorexia nervosa (Suárez-Pinilla et al., 2015).

Treatment of Bulimia Nervosa The treatment of bulimia nervosa has been shown to have about a 40% success rate, defined as (a) eliminating or greatly reducing the cycle of binging followed by inappropriate compen- satory behavior, (b) eating normally, and (c) maintaining a normal weight for the individual’s height and age (Isomaa & Isomaa, 2014). Isomaa and Isomaa (2014) also noted that in follow-up research years after treat- ment ended, up to 85% of those with buli- mia nervosa have either fully or partially recovered. Approximately 30% to 50% will experience relapse (MacDonald, McFarlane, Dionne, David, & Olmsted, 2017). Treat- ment for bulimia nervosa is evidently much more effective than treatment for anorexia nervosa. There are two possible reasons for this. First, because bulimia nervosa is more common, more research has been done on its possible treatments. Antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac) and sertraline (Zoloft) may reduce and/or eliminate the symptoms, especially when combined with CBT (Bernacchi, 2017; Starr & Kreipe, 2014). Second, treatment is more effective because, unlike in anorexia ner- vosa, death due to bulimia nervosa remains relatively rare (Keel & Mitchell, 1997).

The most pressing goal of treatment for bulimia is to extinguish the binge/purge cycles and to reestablish good eating habits, working under the assumption that, at one point, the indi- vidual exhibited healthy or “normal” eating habits. The long-term goal is to examine, and perhaps bring to the surface of the conscious mind, the root causes of the individual’s bulimic behaviors.

callum redgrave-close/iStock/Thinkstock Antidepressants have shown positive results in reducing or eliminating the symptoms of bulimia nervosa.

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Section 7.5 Eating Disorders

Behavioral Therapy Typically, behavioral techniques are used in conjunction with other therapeutic techniques such as cognitive methods and supportive techniques (Bernacci, 2017). A common technique is to ask patients to keep a food diary, which documents their daily meals, what they eat, and any changes they note in their feelings of hunger or fullness. The most important result of keeping a food diary is that it allows patients to objectively look at their eating patterns and behaviors, something that many individuals with bulimia do not (or perhaps cannot) do. In addition, and perhaps more important, this method allows individuals to recognize emo- tional eating. In other words, are any emotions triggering an eating binge, and do individuals eat as a result of an uneasy emotion, or because they are truly hungry?

Cognitive-Behavioral Therapy Cognitive-behavioral therapy focuses on teaching ways to resist the binge/purge impulses and notice the warning signs (Wilson, 2005). Christopher Fair- burn (1985), a major researcher in the field of buli- mia, created a three-step approach to treat bulimia nervosa that has been successful and is often used by today’s helping professionals. The main goal in the three-step approach is to look at individu- als’ eating behavior and to have them look at the consequences of binging. The helping professional examines the physical consequences of binging and purging with the patients and helps them under- stand how ineffective it is to use laxatives or vomit to control their weight. Dieting, especially extreme diets where the daily caloric intake is severely reduced, is also examined in either therapy or edu- cational sessions. These can occur individually or in groups. Next, an eating plan is set up in which many small meals are eaten each day, with no more than three hours between any meals. This planned eat- ing schedule will eliminate the bouncing back and forth between periods of overeating and purging, or restriction, that occur with bulimia nervosa (Fair- burn, 1985).

Next, the helping professional will examine the dysfunctional cognitions, or beliefs, that the individuals have about their appearance and dieting behaviors. Cognitive restructuring, helping patients to recognize and change negative thoughts that lead to binging and subse- quently purging, may be used at this point. The helping professional works with the individu- als to assist them as they discover these irrational thoughts and make plans to change these negative self-statements. Goals include raising the individuals’ self-esteem and helping them realize that they cannot be perfect all of the time.

Stockbyte/Stockbyte/Thinkstock Keeping a food diary allows individuals with bulimia to track patterns in their eating habits, which in turn can help uncover the source of the individuals’ bulimic behaviors.

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Finally, the helping professional will prepare patients for potential relapses and how to han- dle them. They will also work with patients to help them develop realistic beliefs and expec- tations about eating and weight-related issues. Research has demonstrated that these tech- niques lead to the elimination of bulimic symptoms in at least one third to as many as two thirds of individuals with the disorder (Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; Mitchell et al., 2002; Poulson et al., 2014).

Interpersonal Therapy Interpersonal therapy (IPT) may also be an effective treatment modality. IPT focuses on the individual’s current relationships, with particular focus on the family during weekly sessions over four to six months. Communication and problem-solving skills are worked on in order to improve individuals’ interpersonal relationships, and the focus is on what in their relation- ships led to the onset, maintenance, and relapse of bulimia nervosa (Bernacci, 2017; Kass, Rosenthal, Pottackal, & McGann, 2013; Tanofsky-Kraff, Shomaker, Young, & Wilfley, 2016). This therapeutic modality does not focus on the individual’s maladaptive eating behaviors but instead focuses on reducing interpersonal conflicts, especially within the individual’s family.

Psychotropic Medications Research has shown significantly positive outcomes for the use of antidepressants in treating bulimia nervosa (Hay & Claudino, 2012; Starr & Kreipe, 2014). The antidepressants typically used are SSRIs such as fluoxetine (Prozac), which have fewer side effects than others, increas- ing the likelihood of medication compliance. Prozac is the only medication approved by the FDA to treat the binges and inappropriate compensatory behaviors (specifically, purges) of bulimia nervosa. Other SSRIs, such as sertraline (Zoloft), also have proven to be effective.

Treatment of Binge-Eating Disorder A crucial component of making sure that individuals who diet do not regain the weight is to stop the binge eating (see, for example, Fisher et al., 2014). Cognitive-behavioral therapy and interpersonal therapy have both proved to be rather successful in treating BED (Amianto, Ottone, Daga, & Fassino, 2015; Brownley et al., 2016; Fisher et al., 2014; Grilo et al., 2014). Interestingly, using self-help procedures appears to be ineffective in the long-term in treating BED; more effective interventions are required (Fairburn & Murphy, 2015; Grilo et al., 2014). These results were similar to those for subjects who were in therapy groups. Another inter- esting study measured the effectiveness of Prozac in treating BED. Four experimental groups were formed: Prozac alone, placebo, CBT and Prozac, and placebo and CBT. Prozac alone, when compared with placebo alone, showed no significant difference in eliminating BED. When CBT was used in conjunction with Prozac and with placebo, both treatment modalities were more successful than Prozac alone or placebo alone. In fact, 73% of the subjects did not binge for one month after treatment concluded, which the researchers defined as remission (Ramacciotti et al., 2013). So, one can conclude that adding Prozac to CBT does not make the overall treatment more effective. (See Part 4 of Paula Ames’s case in the appendix.)

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A more recent treatment modality for BED is the use of lisdexamfetamine dimesylate (Vyvanse), a stimulant used to treat attention-deficit/hyperactivity disorder in children aged 6 years or older and adults. It was approved to treat BED in 2015. Common side effects are dry mouth, constipation, insomnia, and increased heart rate. Since Vyvanse is a stimulant, there is the potential for abuse and/or dependence. Interestingly, the anticonvulsant topira- mate (Topamax) has been found to reduce binge-eating episodes. Possible side effects include dizziness and kidney stones. Since Topamax is not an FDA-approved treatment for BED, if prescribed it will be off-label. This means that the psychiatrist can legally prescribe Topamax, but it has not been FDA approved to treat the condition for which it is being prescribed. What are your views on off-label prescribing?

Chapter Summary

Sleep Disorders • The two main types of sleep disorders are the dyssomnias and the parasomnias. • Insomnia disorder is characterized by a difficulty falling asleep, maintaining sleep,

or not feeling rested after normal amounts of sleep. • Narcolepsy, a rare condition, is marked by sudden and repeated “attacks” of dream

state (rapid eye movement, or REM) sleep that will also be accompanied by a brief loss of muscle tone, called cataplexy.

• In obstructive sleep apnea hypopnea, the individual may stop breathing for as long as 30 seconds many times during the night. This may occur hundreds of times dur- ing the night, and the victim is unaware that this is occurring.

• The parasomnias are characterized by sleep disturbances that result from unusual or abnormal events that occur during the night.

• Non–REM sleep arousal disorder, sleep terror type, which typically affects children and usually disappears in adolescence, is not related to nightmares, as sleep terrors occur during non-REM sleep.

• Non–REM sleep arousal disorder, sleepwalking type (called somnambulism when it is repeated), is primarily a childhood disorder, occurring during NREM sleep, that disappears around age 15.

Etiologies of Sleep-Wake Disorders • Causes of insomnia may include a failure of the body temperature to drop enough for

the individual to fall asleep; drug and alcohol use; changes in light, noise, or temper- ature; stressful events occurring during the day; fatigue; or a misperception of how much sleep is needed or of how disruptive interrupted sleep can be.

• Some of the sleep-wake disorders, including narcolepsy, run in families; however, this cannot be considered a causal factor.

• Sleep apnea may be associated with trauma.

Treatment of Sleep Disorders • The most commonly used treatment for insomnia is medication, specifically the ben-

zodiazepines (Dalmane) or related medications (such as Ambien). However, negative effects of benzodiazepines include excessive sleepiness and dependence.

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• Short-acting drugs are often the preferred medication choice as they will have stopped working by morning and will not produce daytime drowsiness.

• Stimulants are often prescribed for narcolepsy or hypersomnia. • For breathing-related sleep disorders, such as obstructive sleep apnea hypopnea,

weight loss is often strongly recommended. • Mechanical devices to improve breathing during sleep typically have little success

because of the discomfort they produce. • Simple environmental treatments include making bedtimes several hours later than

normal or using bright light to fool the brain into thinking it’s earlier. • Progressive relaxation techniques have been used with a limited amount of success. • Stimulus control techniques, limiting bedroom activities to sleeping and having sex,

have been used with greater success. • Establishing a good sleep hygiene program is also effective. • One method used to eliminate sleep terrors is scheduled awakenings.

Eating Disorders • People with eating disorders suffer from extreme disturbances in eating behavior

caused by an obsessive and irrational fear of gaining weight. • The individual may have an obsessive and irrational fear of gaining weight (anorexia

nervosa), or may be obsessed with maintaining their weight by binging and then using an inappropriate compensatory behavior to prevent weight gain (bulimia nervosa).

Anorexia Nervosa

• Anorexia nervosa, a condition that can be quite lethal and appears most often in women, is defined as an eating disorder in which the individual refuses to maintain proper body weight and weighs less than the minimally normal amount for their height and age.

• Individuals with anorexia nervosa have an intense fear of gaining weight or becom- ing fat even though they are severely underweight, and they deny the seriousness of the problem or cannot properly perceive how their bodies appear.

• Anorexia nervosa has two subtypes: the restricting type, characterized by the indi- vidual (during the current episode) not regularly engaging in binge-eating or purg- ing behavior, and the binge-eating/purging type, characterized by the individual (during the current episode) regularly engaging in binge-eating or purging behavior.

Bulimia Nervosa

• In bulimia nervosa, individuals binge eat and then expel the food from their bodies, either through purging or nonpurging behavior.

• Binging is characterized by individuals eating an amount of food during a certain period of time that is significantly larger than what most would eat during that time period and under similar circumstances, and by those individuals feeling as though they lack control over their eating binges.

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Binge-Eating Disorder (BED)

• In binge-eating disorder (BED), the individual binges without using compensatory behaviors.

Etiologies of Eating Disorders • One sociocultural factor associated with eating disorders that has been investigated

is Western values and the influence of Western media on what should be the ideal body type.

• Psychological causal factors that have been researched include control issues, a lack of interoceptive awareness, separation problems from the family, and body dissatis- faction issues.

• Biological causal factors that have been investigated include improper serotonin levels, among other hypotheses.

Treatment of Anorexia Nervosa • In treating anorexia nervosa, the immediate goal is to get affected individuals to gain

back a certain amount of weight and to attempt to normalize their eating patterns. • Interpersonal therapy, ideally using the family therapy modality, is also used, and

cognitive-behavioral techniques seem to be somewhat successful. Medications are not recommended for treating anorexia nervosa, as none has been proven successful.

Treatment of Bulimia Nervosa • The most pressing goal in treatment is to extinguish the binge/purge cycles and to

reestablish good eating habits. • The long-term goal is to examine, and perhaps bring to the surface of the conscious

mind, the root causes of the individual’s bulimic behaviors. • Standard modalities for treating bulimia include individual and family therapy, spe-

cifically cognitive-behavioral therapies and interpersonal behavior therapies. • Antidepressants, specifically the SSRIs Prozac and Zoloft, have been proven to be

quite successful in reducing the binge/purge cycles. • Tricyclic antidepressants (TCAs) have also proven to be effective, but their side-

effect profiles (and the potential for a lethal overdose) do not warrant their usage in lieu of SSRIs.

Treatment of Binge-Eating Disorder • Cognitive-behavioral therapy and interpersonal therapy have been successful in

treating BED. • Self-help procedures have not proven to be effective in the long term.

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Key Terms anorexia nervosa An eating disorder in which the individual avoids consuming food due to an unrealistic fear of gaining weight, even though the individual is seriously underweight at present. It literally means “nervous loss of appetite.”

avoidant/restrictive disorder A feeding disorder characterized by inadequate eating.

binge eating Eating within a specific time period an amount of food that is significantly larger than most people would eat during that time period under similar circum- stances; may range from 6,000 to upwards of 10,000 calories at one sitting.

binge-eating disorder (BED) Involves binging episodes similar to those found in bulimia nervosa but without the inappropri- ate compensatory behaviors (e.g., purging, self-starvation).

binge-eating/purging type A subtype of anorexia nervosa characterized by the indi- vidual, during the current episode, regularly engaging in binge-eating or purging behav- ior (that is, self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

body image How an individual thinks he or she appears to others.

breathing-related sleep disorders An illness caused by sleep-related breathing difficulties that lead to excessive sleepiness or insomnia. These disorders are subdi- vided into obstructive sleep apnea hypop- nea, central sleep apnea, and sleep-related hypoventilation.

bulimia nervosa An eating disorder char- acterized by the individual’s eating and then expelling the food from the body. The indi- vidual is deathly afraid of gaining weight. It literally means “hunger of an ox.”

cataplexy A brief loss of muscle tone that often accompanies narcolepsy.

Critical Thinking Questions

1. A common treatment modality for insomnia disorder is prescribing medications to help the individual fall asleep. One problem with these medications is that it is rela- tively easy to become addicted to them. Discuss your views on using medications to treat insomnia disorder, noting both positive and negative outcomes of using them.

2. Some of the parasomnias, like non–REM sleep arousal disorder with sleep terrors and non–REM sleep arousal disorder with sleepwalking, tend to disappear by adult- hood. Discuss and explain some of the possible reasons for this.

3. Anorexia nervosa is a difficult disorder to comprehend. Give your perspective on what might cause adolescents to starve themselves to the point of death (in some instances), and discuss the most effective treatment methods for anorexia nervosa.

4. Bulimia nervosa is easier to understand and to treat than anorexia nervosa, and it is also more common. What might some of the reasons be for these differences?

5. BED is a new diagnosis in the DSM–5. Describe and discuss some reasons why BED is now a DSM–5 diagnostic category.

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central sleep apnea The occurrence of, minimally, five or more central apneas per hour of sleep.

circadian rhythm sleep-wake disorders A series of sleep-wake problems in which the individual has difficulty sleeping at the times required for their work, school, or other aspect of their lives.

cognitive restructuring A technique psy- chologists use to help their patients recognize and change negative thoughts that lead them to binge and subsequently purge, or to engage in other self-destructive behaviors.

continuous positive airway pressure (CPAP) A machine used in sleep apnea therapy. By delivering enough air pressure to a face mask, it keeps the upper airway pas- sages open while the user is asleep.

diuretics Medications that increase urination and therefore have a tendency to dry someone out and perhaps lead to weight loss.

dyssomnias Irregularities or abnormali- ties in the amount, quality, or timing of sleep. Included in this category are disor- ders initiating or maintaining sleep, which includes nighttime wakefulness, or excessive sleepiness.

eating disorders Illnesses that occur when an individual suffers extreme disturbances in eating behavior caused by an obsessive and irrational fear of gaining weight.

faulty cognitions Sometimes called irrational beliefs, these are irrational or false beliefs that result in self-defeating behavior(s), which can lead to self-destruc- tive or maladaptive behaviors.

food diary A written record of a patient’s daily eating habits, food intake, and so on, that is to be shared with a clinician on a weekly basis. Ideally the food diary will also include binges, purges, and the patient’s feelings when he or she eats.

hypersomnolence disorder A sleep-wake disorder characterized by excessive sleepi- ness even though the individual may have slept at least seven to nine hours.

inappropriate compensatory behav- iors Behaviors designed to counterbalance and counteract the effects of an eating binge. They are designed to ensure that the indi- vidual with bulimia does not in fact gain any weight; they also serve to help the individual regain self-control. The purging seems to alleviate any anxiety caused by the fear of gaining weight.

insomnia disorder An inability to sleep characterized by a difficulty falling asleep, maintaining sleep, or not feeling rested after normal amounts of sleep.

insomnia A disturbance in the amount, quality, or timing of sleep that occurs at least three nights per week for at least 3 months.

interoceptive awareness An individual’s awareness of his or her internal cues, includ- ing emotional states and hunger.

irrational beliefs Ways of thinking that can lead to self-destructive or maladaptive behaviors. One example would be the state- ment “I must be loved by everyone.” This is impossible, as no one person, real or ficti- tious, is loved by everyone.

narcolepsy A sleep disorder marked by sudden and repeated “attacks” of dream state (REM) sleep that will also be accom- panied by a brief loss of muscle tone, called cataplexy.

nightmare disorder The frequent occurence of extended and well- remembered dreams that usually have themes of avoiding threats to survival, secu- rity, and physical integrity. These dreams usually occur during the second half of a major sleep episode.

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nightmares Dreams that arouse feelings of intense fear, horror, and distress.

non–rapid eye movement sleep arousal disorder, sleep terror type A childhood disorder that occurs during NREM sleep. Sufferers experience sleep terrors and awaken screaming very loudly.

non–rapid eye movement sleep arousal disorders, sleepwalking type Primarily a childhood disorder that occurs during NREM sleep, typically during the first few hours of sleep. Affected individuals will usually leave their beds repeatedly during the night and walk around without being conscious of doing so or being able to recall doing so later once awake.

obesity Being minimally 30 pounds over- weight, as defined by the National Institutes of Health.

obstructive sleep apnea hypopnea A breathing-related sleep disorder during which the individual may stop breathing for as long as 30 seconds many times during the night.

orexin (hypocretin) A neurotransmitter that regulates and is involved with arousal, wakefulness, and appetite.

parasomnias Sleep disturbances that result from unusual or abnormal events that occur during the night.

pica A feeding disorder in which the indi- vidual will eat things such as dirt, laundry starch, and chalk.

polysomnography (sleep study) A test that records an individual’s brain waves, blood oxygen level, heart rate and breathing, as well as eye and leg movements in order to diagnose sleep disorders.

purge The elimination of all of the food that was consumed during a prior binge by an individual with anorexia or bulimia. It is only a purge if the food is somehow forced out of the body by inappropriate compensatory behaviors.

restricting type A subtype of anorexia ner- vosa characterized by the individual being meticulous, perhaps obsessive, about how much food he or she eats at a given time, and his or her caloric intake at each meal or on a daily basis. Such individuals do not regularly engage in binge-eating or purging behavior.

rumination disorder A feeding disorder marked by regurgitation of food.

sleep-related hypoventilation A sleep dis- order in which the individual has decreased respiration while asleep as demonstrated by elevated carbon dioxide levels; diagnosed by polysomnography.

sleep terrors A sleep disorder (but not a DSM–5 diagnostic category) that typically affects children and causes them to awaken with a frighteningly loud scream; the child will have a rapid heart rate, be very upset, and often be sweating profusely. Children do not recall sleep terrors.

somnambulism Recurrence of sleepwalk- ing episodes.

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