Feeding/Eating, Elimination, and Sleep-Wake Disor

Why This Topic Matters for Your EPPP Prep

You're studying for the EPPP, which means you're preparing to be someone who truly helps people. The disorders we're covering today (feeding and eating disorders, elimination disorders, and sleep-wake disorders) might seem less dramatic than some other psychological conditions, but they're absolutely essential to understand. These disorders affect physical health directly, sometimes in life-threatening ways. They're also surprisingly common: you'll encounter them in nearly any practice setting, from pediatric clinics to adult therapy offices. Plus, the EPPP loves testing on the specifics of these disorders because they require you to distinguish between similar presentations and remember precise diagnostic criteria.

Let's break down these three disorder categories in a way that makes sense and sticks with you through exam day and beyond.

Feeding and Eating Disorders: When Food Becomes the Problem

Eating disorders involve persistent disturbances in eating or eating-related behavior that mess with physical health or how someone functions in daily life. The key word here is "persistent". We're not talking about occasional dieting or skipping breakfast when you're running late. These are patterns that take over someone's life.

Pica: Eating What Isn't Food

Pica involves persistently eating non-nutritive, non-food substances for at least one month. We're talking about things like paper, paint, coffee grounds, or dirt. This behavior has to be inappropriate for the person's developmental level and can't be something that's culturally or socially acceptable in their community.

While pica can happen at any age, it's most common in children. There's also an elevated rate among pregnant women. The dangers are real: intestinal obstruction, lead poisoning from paint chips, and other medical complications that can require emergency intervention.

{{M}}Think of it like someone repeatedly putting diesel fuel in a regular gasoline car, the system isn't designed to process what's being put in, and serious damage results.{{/M}}

Anorexia Nervosa: The Restriction Disorder

Anorexia nervosa is one of the deadliest psychiatric disorders, and understanding its criteria is crucial for the exam. Here's what you need for a diagnosis:

Core Diagnostic Features:

Notice the "OR" statements in the table. You don't need all symptoms, for example, someone might not verbally express fear of weight gain but might engage in behaviors that prevent it (like exercising for hours daily or hiding food).

Important Specifiers to Know:

• Type: Restricting type (just restricts food) vs. binge-eating/purging type (also binges and purges)
• Severity: Based on current body mass index (BMI)
• Course: Partial remission or full remission

Anorexia frequently co-occurs with depression or anxiety disorders, especially obsessive-compulsive disorder. Research shows that anxiety often comes first, then anorexia develops. The medical complications are severe because nearly every major organ system is affected by malnutrition and extreme weight loss.

Treatment Challenges and Approaches:

Anorexia is notoriously difficult to treat. {{M}}Imagine trying to help someone who genuinely believes that the thing slowly killing them is actually keeping them safe. That's the treatment paradox with anorexia.{{/M}} People with this disorder often deny they have a problem and resist treatment.

Treatment goals follow a logical sequence:

1. Immediate: Restore healthy weight and address physical complications
2. Next: Increase motivation, provide nutrition education, change problematic beliefs and attitudes
3. Ongoing: Treat co-occurring conditions (low self-esteem, impulse control), provide family therapy when appropriate, develop relapse prevention strategies

Evidence-Based Treatments:

• CBT for Anorexia Nervosa: A post-hospitalization intervention assuming that concerns about shape and weight lead to dietary restriction that maintains symptoms. Uses behavioral strategies for regular eating and cognitive strategies to change problematic thinking.

• CBT-E (Enhanced CBT): A transdiagnostic treatment proposing all eating disorders share the same core problem, giving too much value to physical appearance and weight. It's personalized and flexible, focusing on whatever factors maintain that specific patient's symptoms.

• Family-Based Treatment (FBT): An outpatient intervention for medically stable adolescents with three phases:

  1. Parents take charge of nutritional rehabilitation and weight restoration
  2. Control gradually returns to the adolescent
  3. Address adolescent developmental issues and independence

Medication: Results are inconsistent. Some studies show olanzapine helps with initial weight gain and fluoxetine helps maintain weight, but findings vary enough that many experts recommend medications only for treating comorbid depression and anxiety.

Bulimia Nervosa: The Binge-Purge Cycle

Bulimia nervosa involves a cycle of binge eating followed by compensatory behaviors. Here's what you need to know:

Diagnostic Requirements:

Key Distinctions from Anorexia:

Most people with bulimia are normal weight or overweight. That's a major difference from anorexia. The medical complications come primarily from the compensatory behaviors rather than starvation. Purging causes dental erosion, gastroesophageal reflux, and dehydration. That dehydration leads to electrolyte imbalances that can cause heart arrhythmias and death.

Treatment Approaches:

Treatment typically combines nutritional rehabilitation with psychotherapy:

• CBT and CBT-E: Same approaches as for anorexia, both effective
• Interpersonal Therapy (IPT): Works as well as CBT but takes longer to show effects
• FBT for Bulimia: Similar to FBT for anorexia but with a key difference. Adolescents with bulimia often experience their symptoms as ego-dystonic (unwanted), so they're more motivated to change. Treatment is more collaborative, with adolescent and parents working together.

Medication: Antidepressants, especially fluoxetine, help both with comorbid depression and with reducing binge eating and purging. Even in patients without depression.

Binge-Eating Disorder: Binges Without Compensatory Behaviors

Binge-eating disorder (BED) is the newest addition to the major eating disorders category. Here's what distinguishes it:

Diagnostic Criteria:

• Recurrent binge eating episodes (eating more than most people would in similar circumstances, with sense of lack of control)
• At least three of these five characteristics:
  1. Eating more rapidly than usual
  2. Eating until uncomfortably full
  3. Eating large amounts when not hungry
  4. Eating alone due to embarrassment
  5. Feeling disgusted, depressed, or very guilty afterward
• Episodes occur at least once weekly for 3+ months
• Crucially: No recurrent inappropriate compensatory behaviors (this distinguishes BED from bulimia)

Key Points for the Exam:

• BED is 2-3 times more common in women than men
• Can occur at any weight (normal, overweight, or obese)
• Better treatment response than bulimia generally
• Timing matters: In BED, dieting often follows the disorder's onset; in bulimia, dysfunctional dieting often precedes it

Treatment:

CBT-E and IPT are both evidence-based, though CBT-E may be more effective. Medications (SSRIs, topiramate, lisdexamfetamine) have been studied, but medication alone is typically less effective than CBT, and combining them isn't usually better than CBT alone.

Important clinical note: When treating someone with BED who is also overweight or obese, address the binge-eating before or during weight loss efforts, not after.

Elimination Disorders: When Bodily Control Is the Issue

Elimination disorders involve problems with urination or defecation control. For the EPPP, you mainly need to know about enuresis.

Enuresis: Bedwetting and Daytime Accidents

Diagnostic Criteria:

• Repeated urination into bed or clothing
• Either occurring 2+ times weekly for 3+ consecutive months OR causing significant distress/impairment
• Always or usually involuntary
• Not due to substance use or medical condition
• Person must be at least 5 years old (or equivalent developmental level)

Subtypes:

• Nocturnal only (nighttime)
• Diurnal only (daytime)
• Nocturnal and diurnal (both)

Treatment:

The moisture alarm (bell-and-pad) is the most common treatment for nocturnal enuresis. {{M}}It works like a very specific type of classical conditioning, when the child begins to urinate, a bell rings, waking them up and helping them learn to recognize the sensation of a full bladder.{{/M}}

The antidiuretic hormone desmopressin also works for many children but has a high relapse rate when discontinued.

Sleep-Wake Disorders: When Rest Becomes a Problem

Sleep-wake disorders involve problems with sleep quality, timing, or amount that cause daytime distress and impairment. These are incredibly common, and you'll definitely see questions about them on the EPPP.

Insomnia Disorder: Can't Sleep, Won't Sleep

Insomnia disorder is characterized by dissatisfaction with sleep quality or quantity. For diagnosis, the person needs one or more of these symptoms:

Critical Diagnostic Points:

• Must occur 3+ nights per week
• Must be present for 3+ months
• Must occur despite sufficient opportunities for sleep
• Must cause significant distress or impaired functioning

Sleep maintenance insomnia is the most common single type, but having all three types together is most common overall.

Important Research Finding:

When people with insomnia report their sleep patterns, they typically overestimate how long it takes them to fall asleep, overestimate time awake during the night, and underestimate total sleep time compared to objective measures like polysomnography. {{M}}It's like how a frustrating commute feels longer than it actually is, the subjective experience differs from the objective reality.{{/M}}

Treatment: CBT-I (The Gold Standard)

Cognitive Behavior Therapy for Insomnia (CBT-I) is considered the first-line treatment. It has multiple components:

1. Stimulus control: Strengthens bedroom and bed as cues for sleep (go to bed only when tired, use bedroom only for sleep and sex)

2. Sleep restriction: Improves sleep efficiency by initially restricting time in bed to match actual sleep time, then gradually increasing as efficiency improves

3. Sleep hygiene training: Education about behaviors that help or hurt sleep (comfortable bedroom environment, limiting caffeine, getting out of bed if unable to sleep for 20 minutes)

4. Relaxation training: Meditation, progressive muscle relaxation, other techniques that facilitate relaxation

5. Cognitive restructuring: Identifying and replacing negative thoughts contributing to insomnia

Alternative: CT-I (Cognitive Therapy for Insomnia)

CT-I is based on Harvey's cognitive model and focuses on reversing problematic cognitive processes that occur day and night:

• Sleep-related worry and rumination causing arousal ("If I don't sleep, tomorrow will be terrible")
• Selective attention to sleep-related threats (monitoring for fatigue all day)
• Unhelpful beliefs about sleep (faulty assumptions about what's normal)
• Misperceptions about sleep and daytime deficits
• Safety behaviors that actually worsen insomnia (checking time constantly, avoiding social activities, exercising or drinking alcohol before bed to force sleep)

Narcolepsy: Irresistible Sleep Attacks

Narcolepsy involves attacks of irrepressible need to sleep, causing sleep or daytime naps at least three times weekly for 3+ months.

Diagnosis Requires ONE of These:

• Episodes of cataplexy (loss of muscle tone)
• Hypocretin deficiency
• REM sleep latency of 15 minutes or less on polysomnography

Associated Features:

Many people with narcolepsy also experience:

• Hypnagogic hallucinations: Vivid hallucinations just before falling asleep
• Hypnopompic hallucinations: Vivid hallucinations just after awakening
• Sleep paralysis: Inability to move when falling asleep or awakening

Because cataplexy is often triggered by strong emotions, people with narcolepsy may try to control their emotions to prevent sleep episodes. {{M}}Imagine having to suppress laughter at a funny moment because laughing might literally make you collapse. That's the daily reality for someone with narcolepsy and cataplexy.{{/M}}

Treatment Approach:

Treatment combines behavioral strategies and medication:

• Behavioral: Good sleep habits, scheduled daytime naps, staying active
• Medications for alertness: Modafinil/armodafinil (increase dopamine), amphetamines/methylphenidate (increase dopamine, serotonin, norepinephrine)
• Medications for cataplexy: Antidepressants (venlafaxine, fluoxetine, clomipramine)
• Sodium oxybate: For patients not responding to other treatments; taken at bedtime to improve deep sleep and reduce cataplexy and daytime sleepiness

Non-REM Sleep Arousal Disorders: Sleepwalking and Sleep Terrors

These disorders involve incomplete awakening from sleep, usually during Stage 3 or 4 sleep in the first third of a major sleep period.

Sleepwalking:

• Getting out of bed and walking during sleep
• May include sleep-related eating or sexual behavior
• Person is unresponsive to attempts to awaken or comfort
• Little or no memory upon awakening

Sleep Terrors:

• Abrupt arousal usually starting with panicky scream
• Intense fear with autonomic arousal (racing heart, rapid breathing)
• Person is unresponsive to attempts to awaken or comfort
• Little or no memory of dream imagery, can't recall episode

Both occur most often in childhood and decrease with age.

Nightmare Disorder: Bad Dreams That Cause Problems

Nightmare disorder involves repeated occurrences of extended, extremely upsetting, and well-remembered dreams, usually involving threats to survival, security, or physical integrity.

Key Characteristics:

• Usually occur during REM sleep in the second half of a major sleep period
• When awakened during a nightmare, the person is oriented and alert
• May continue experiencing dysphoric mood after awakening

This is different from sleep terrors. People with nightmare disorder wake up oriented and remember the dream, while people experiencing sleep terrors don't remember and aren't responsive when it's happening.

Common Misconceptions to Avoid

1. "Anorexia and bulimia are just about vanity": These are serious psychiatric disorders with neurobiological components, often co-occurring with anxiety and depression. They're not choices or phases.

2. "People with bulimia are always thin": Actually, most people with bulimia are normal weight or overweight, distinguishing it from anorexia.

3. "Binge-eating disorder is just overeating": BED involves specific patterns of eating with loss of control and significant psychological distress, meeting particular diagnostic criteria.

4. "Insomnia is just trouble falling asleep": Insomnia has three types (initial, middle, and late), and people can have any combination. Sleep maintenance insomnia is actually the most common single type.

5. "Medication is the best treatment for insomnia": CBT-I is actually considered the first-line treatment, with better long-term outcomes than medication.

6. "Narcolepsy is just being really tired": Narcolepsy is a specific neurological disorder involving REM sleep dysfunction, often with cataplexy, hallucinations, and sleep paralysis.

Practice Tips for Remembering

For Eating Disorders, use the "BAN" mnemonic:

• Binge-eating disorder: Binges WITHOUT compensation
• Anorexia nervosa: LOW weight, restriction
• Nervosa (bulimia): Normal weight, WITH compensation

For Insomnia Types, remember "I'M LATE":

• Initial insomnia (trouble falling asleep)
• Middle insomnia (waking during night). Most common single type
• LATE insomnia (early morning awakening)

For Narcolepsy, think "CHINS":

• Cataplexy
• Hypocretin deficiency
• Irresistible sleep attacks
• Naps (at least 3x weekly for 3+ months)
• Short REM latency (15 minutes or less)

For Treatment Approaches:

• CBT-E is Everywhere (transdiagnostic. Works across eating disorders)
• FBT has three Family phases (1. Parents in charge, 2. Return control, 3. Independence)
• CBT-I has 5 components (stimulus control, sleep restriction, sleep hygiene, relaxation, cognitive restructuring)

Key Takeaways

• Eating disorders share concern about weight/shape but differ critically in weight status and compensatory behaviors
• Anorexia nervosa is life-threatening, difficult to treat due to denial, and often requires weight restoration before psychological work
• Bulimia nervosa involves normal weight, binge-purge cycles, and medical complications from purging behaviors
• Binge-eating disorder has binges WITHOUT compensation and typically better treatment response than other eating disorders
• CBT-E is transdiagnostic for eating disorders; FBT is specifically for adolescents with family involvement
• Enuresis requires age 5+ years and the moisture alarm is the most common treatment
• Insomnia disorder requires 3+ nights weekly for 3+ months with three possible symptom types
• CBT-I is first-line treatment for insomnia with five key components
• Narcolepsy requires irresistible sleep attacks plus cataplexy, hypocretin deficiency, OR short REM latency
• Non-REM sleep arousal disorders (sleepwalking, sleep terrors) involve incomplete awakening with no memory
• Nightmare disorder involves remembered, distressing dreams during REM sleep with person oriented upon awakening

These disorders appear regularly on the EPPP because they require you to distinguish between similar presentations and remember specific diagnostic criteria and evidence-based treatments. Focus on the distinguishing features, duration requirements, and treatment approaches that have research support. You've got this!