DSM-5 Eating and Feeding Disorders

 Anorexia Nervosa
 Bulumia Nervosa
 Binge Eating Disorder
 Avoidant/restrictive food intake disorder (ARFID)
 Pica.
 Rumination disorder

Anorexia Nervosa

Anorexia nervosa is a syndrome characterized by three essential criteria:

 The first is a self-induced starvation to a significant degree--a behavior.

 The second is a relentless drive for thinness or a morbid fear of fatness- -a
psychopathology.
 The third criterion is the presence of medical signs and symptoms resulting from
starvation--a physiological symptomatology.

Two subtypes of anorexia nervosa exist: restricting and binge/purge.

Clinical Features

An intense fear of gaining weight and becoming obese is present in all patients with the disorder and
undoubtedly contributes to their lack of interest in, and even resistance to, therapy.

Most aberrant behavior directed toward losing weight occurs in secret. Patients with anorexia
nervosa usually refuse to eat with their families or in public places.

They lose weight by drastically reducing their total food intake, with a disproportionate decrease in
highcarbohydrate and fatty foods.

Some patients cannot continuously control their voluntary restriction of food intake and so have
eating binges. These binges usually occur secretly and often at night and are frequently followed by
self-induced vomiting.

Patients tend to be rigid and perfectionist, and somatic complaints, especially epigastric discomfort,
are usual. Compulsive stealing, usually of candies and laxatives but occasionally of clothes and other
items, may occur.

Patients usually come to medical attention when their weight loss becomes apparent.

Comorbidity

 Depression  Anxiety disorders  Obsessive compulsive disorder  Autism spectrum disorders

Subtypes

1- the food-restricting category

2- the purging category

In the food-restricting category, present in approximately 50 percent of cases, food intake is highly
restricted (usually with attempts to consume fewer than 300 to 500 calories per day and no fat
grams), and the patient may be relentlessly and compulsively overactive.

In the purging subtype, patients attempts at rigorous dieting with intermittent binge or purge
episodes. Purging represents a secondary compensation for the unwanted calories, most often
accomplished by selfinduced vomiting, frequently by laxative abuse, less frequently by diuretics,
and occasionally with emetics.

Sometimes, repetitive purging occurs without prior binge eating, after ingesting only relatively few
calories.  BULIMIA İLE AYIRICI NOKTA

Both types may be socially isolated and have depressive disorder symptoms and diminished sexual
interest. Overexercising and perfectionistic traits are also common in both types.

 Those who binge eat and purge tend to have families in which some members are obese, and
they themselves have histories of heavier body weights before the disorder than do
persons with the restricting type.
 Binge eating-purging persons are likely to be associated with substance abuse, impulse
control disorders, and personality disorders.
 Persons with restricting anorexia nervosa often have obsessivecompulsive traits with
respect to food and other matters.
 Some persons with anorexia nervosa may purge but not binge.

Biological factors

Some authors have proposed a hypothalamic-pituitary axis (neuroendocrine) dysfunction.

Some studies have shown evidence for dysfunction in serotonin, dopamine, and norepinephrine,
three neurotransmitters involved in regulating eating behavior.

Psychological and Psychodynamic factors

These patients typically lack a sense of autonomy and selfhood. Many experience their bodies as
somehow under the control of their parents, so that self-starvation may be an effort to gain
validation as a unique and special person. Only through acts of extraordinary self-discipline can an
anorectic patient develop a sense of autonomy ad selfhood.

Psychoanalytic clinicians who treat patients with anorexia nervosa generally agree that these young
patients have been unable to separate psychologically from their mothers. The body may be
perceived as though it were inhabited by the introject of an intrusive and unempathic mother.
Starvation may unconsciously mean destroying intrusive internal object. Other theories have focused
on fantasies of oral impregnation (becoming pregnant by eating).

Clinical assessment
Differential Diagnosis

 Medical illnesses (cancer, brain tumor)

 Depressive disorders (loss of appettite)
 Psychotic disorders (delusions of poisioning)
 Somatization disorder
 Bulumia nervosa (binge eating episodes and weight within a normal range)

Course and prognosis

Treatment

Hospitalization  The first consideration in the treatment of anorexia nervosa is to restore patients'
nutritional state; dehydration, starvation, and electrolyte imbalances can seriously compromise
health and in some cases, lead to death.

Inpatient psychiatric programs  Inpatient psychiatric programs for patients with anorexia nervosa
generally use a combination of a behavioral management approach, individual psychotherapy, family
education and therapy, and, in some cases, psychotropic medications.

Bulumia Nervosa

Bulimia nervosa is characterized by episodes of binge eating combined with inappropriate ways of
stopping weight gain.

Physical discomfort-for example, abdominal pain or nausea terminates the binge eating, which is
often followed by feelings of guilt, depression, or self-disgust. Unlike patients with anorexia nervosa,
those with bulimia nervosa typically maintain a normal body weight.
For some patients, bulimia nervosa may represent a failed attempt at anorexia nervosa, sharing the
goal of becoming very thin, but occurring in an individual less able to sustain prolonged semi-
starvation or severe hunger as consistently as classic restricting anorexia nervosa patients.

Regardless of the reason, eating binges provoke panic as individuals feel that their eating has been
out of control. The unwanted binges lead to secondary attempts to avoid the feared weight gain by a
variety of compensatory behaviors, such as purging or excessive exercise.

Bulimia nervosa is present when

(1) episodes of binge eating occurs relatively frequently (once a week or more) for at least 3
months;

(2) compensatory behaviors are practiced after binge eating to prevent weight gain, primaily self-
induced vomiting, laxative abuse, diuretics, enemas, abuse of emetics and less commonly severe
dieting and stenuous exercise (20 percent of cases);

(3) weight is not severely lowered as in anorexia nervosa; and

(4) the patient has a morbid fear of fatness, a relentless drive for thinness, or both and a
disproportionate amount of self-evaluation that depends on body weight and shape.

Clinical features

Vomiting is common and is usually induced by sticking a finger down the throat, although some
patients are able to vomit at will.

Depression, sometimes called post-binge anguish, often follows the episode. During binges,
patients eat food that is sweet, high in calories, and generally soft or smooth textured, such as cakes
and pastry. Some patients prefer bulky foods without regard to taste.

Bulimia nervosa occurs in persons with high rates of mood disorders and impulse control disorders.
Bulimia nervosa is also reported to occur in those at risk for substance-related disorders and a
variety of personality disorders. Patients with bulimia nervosa also have increased rates of anxiety
disorders, bipolar disorder, dissociative disorders, and histories of sexual abuse.

They often meet criteria for borderline personality disorder and other mixed personality disorders
and, not infrequently, bipolar II disorder.
Biological Factors

Some investigators have attempted to associate cycles of binging and purging with various
neurotransmitters. Because antidepressants often benefit patients with bulimia nervosa and because
serotonin has been linked to satiety, serotonin and norepinephrine have been implicated.

Binge Eating Disorder

Individuals with binge eating disorder engage in recurrent binge eating during which they eat an
abnormally large amount of food over a short time.

Unlike bulimia nervosa, patients with binge eating disorder do not compensate in any way after a
binge episode (e.g., laxative use).

Binge episodes often occur in private, generally include foods of dense caloric content, and, during
the binge, the person feels he or she cannot control his or her eating.

 Binge eating disorder is the most common eating disorder.

 It is more common in females than in males.
To be diagnosed wit binge eating disorder the binges must be characterized by four features:

(1) eating more rapidly than normal and to the point of being uncomfortably full,

(2) eating large amounts of food even when not hungry,

(3) eating alone, and

(4) feeling guilty or otherwise upset about the episode.  Binges must occur at least once a week
for at least 3 months

Pica
Rumination Disorder

Avoidant/restrictive food intake disorder

Sleep – Wake Disorders

Sleep is a process the brain requires for proper functioning. Prolonged sleep deprivation leads to
severe physical and cognitive impairment.

Sleep is made up of two physiological states:

1. non-rapid eye movement (NREM) sleep and

2. rapid eye movement (REM) sleep.

In NREM sleep, which is composed of stages 1 through 4, most physiological functions are markedly
lower than in wakefulness.

REM sleep is a qualitatively different kind of sleep, characterized by a high level of brain activity and
physiological activity levels similar to those in wakefulness.

About 90 minutes after sleep onset, NREM yields to the first REM episode of the night.

This REM latency of 90 minutes is a consistent finding in normal adults; shortening of REM latency
frequently occurs with such disorders as narcolepsy and depressive disorders.

NREM sleep

 In normal persons, NREM sleep is a peaceful state relative to waking. The pulse rate is
typically slowed five to ten beats a minute below the level of restful waking and is very
regular.
 Respiration is similarly affected, and blood pressure also tends to be low.
 Episodic, involuntary body movements are present in NREM sleep.

REM Sleep

 REM sleep has also been termed paradoxical sleep. Pulse, respiration, and blood pressure in
humas are all high during REM sleep-much higher than during NREM sleep and often higher
than during waking.
 Another physiological change that occurs during REM sleep is the near-total paralysis of the
skeletal (postural) muscles. Because of this motor inhibition, body movement is absent
during REM sleep.
 Probably the most distinctive feature of REM sleep is dreaming.

Sleep Cycle

The cyclical nature of sleep is regular; a REM period occurs about every 90 to 100 minutes during
the night. Most REM periods occur in the last third of the night, whereas most stage 4 sleep occurs
in the first third of the night.
Sleep deprivation

Prolonged periods of sleep deprivation sometimes lead to ego disorganization, hallucinations, and
delusions.

Depriving persons of REM sleep by awakening them at the beginning of REM cycles increases the
number of REM periods and the amount of REM sleep (rebound increase) when they are allowed to
sleep without interruption. REM-deprived patients may exhibit irritability and lethargy.

SLEEP DISORDERS

1. Insomnia Disorder

2. Hypersomnolence Disorder

3. Narcolepsy

4. Breathing-Related Sleep Disorders:

o Obstructive Sleep Apnea Hypopnea

o Central Sleep Apnea
o Sleep-Related Hypoventilation

5. Circadian Rhythm Sleep-Wake Disorders:

o Delayed sleep phase type

o Advanced sleep phase type
o Irregular sleep-wake type
o Non-24-hour sleep-wake type
o Shift work type
o Unspecified type

6. N-REM Sleep Arousal Disorders: a. Sleepwalking type b. Sleep terror type

7. Nightmare Disorder

8. Rapid Eye Movement Sleep Behavior Disorder

9. Restless Legs Syndrome

10. Substance/Medication-Induced Sleep Disorder

INSOMNIA DISORDER

Insomnia is defined as difficulty initiating or maintaining sleep. It is the most common sleep
complaint and may be transient or persistent.

DSM-5 defines insomnia disorder as dissatisfaction with sleep quantity or quality associated with
one or more of the following symptoms:

 difficulty in initiating sleep,

 difficulty in maintaining sleep with frequent awakenings or problems returning to sleep, and
 early morning awakening with inability to return to sleep

A brief period of insomnia is most often associated with anxiety, either as a sequela to an anxious
experience or in anticipation of an anxiety-provoking experience

Stimulus Control Therapy

 The first rule is, go to bed only when sleepy to maximize success.
 Second, use the bed only for sleeping. Do not watch television in bed, do not read, do not
eat, and do not talk on the telephone while in bed.
 Third, do not lie in bed and become frustrated if unable to sleep. After a few minutes (do
not watch the clock), get up, go to another room, and do something nonarousing until
sleepiness returns. The goal is to associate the bed with rapid sleep onset!! Rule three
should be repeated as often as needed.

NARCOLEPSY

Narcolepsy is a condition characterized by excessive sleepiness, as well as the intrusion of aspects of

REM sleep into the waking state.

The REM sleep includes hypnagogic and hypnopompic hallucinations, cataplexy, and sleep
paralysis. The appearance of REM sleep within 10 minutes of sleep onset (sleep onset REM periods)
is also considered evidence of narcolepsy.

Often associated with the problem is cataplexy, a sudden loss of muscle tone, such as jaw drop,
head drop, weakness of the knees, or paralysis of all skeletal muscles with collapse.

Other symptoms include hypnagogic or hypnopompic hallucinations, which are vivid perceptual
experiences, either auditory or visual, occurring at sleep onset or on awakening.

When the diagnosis is not clinically clear, a nighttime polysomnographic recording reveals a
characteristic sleep-onset REM period.

Narcolepsy is the prototypical example of sleepiness produced by a basic central nervous system
dysfunction of sleep mechanisms.

The etiology stems from a genetically triggered hypocretin dysfunction and deficit. It has become
apparent that the hypocretin system plays a critical role in narcolepsy.
PARASOMNIAS

Parasomnias are sometimes referred to as disorders of partial arousal.

Many parasomnias can be seen as overlaps or intrusions of one basic sleep-wake state into another.
Wakefulness, NREM sleep, and REM sleep can be characterized as three basic states that differ in
their neurological organization.

 During wakefulness, both the body and brain are active.

 In NREM sleep, both the body and brain are much less active.
 REM sleep, however, pairs an atonic body with an active brain (capable of creating
elaborate dream fantasies).

For example, sleepwalking and sleep terrors involve momentary or partial wakeful behaviors
suddenly occurring in NREM (slow wave) sleep. Similarly, isolated sleep paralysis is the persistence
of REM sleep atonia into the wakefulness transition, whereas REM sleep behavior disorder is the
failure of the mechanism, creating paralytic atonia such that individuals literally act out their dreams.

NREM Sleep Arousal Disorders

Sleepwalking

It is sometimes called «somnambulism», and individuals can engage in a variety of complex

behaviors while unconscious.

Sleep Terrors

Sleep terror disorder is an arousal in the first third of the night during deep NREM (stages 3 and 4)
sleep.

REM Sleep Disorder

Nightmare Disorder.

Nightmares are frightening or terrifying dreams. They produce sympathetic activation and ultimately
awaken the dreamer.

Nightmares occur in REM sleep and usually evolve from a long, complicated dream that becomes
increasingly frightening. The person having been aroused to wakefulness, he or she typically
remembers the dream (in contrast to sleep terrors).

Restless legs syndrome (RLS)

Restless legs syndrome (RLS) is a common sensorimotor disorder characterized by an urge to move
that appears during rest in the evening or night and that disappears or improves with movement.
Patients with RLS often display periodic leg movements during sleep or resting wakefulness.

RLS occurs alone or with comorbidities, for example, iron deficiency and kidney disease, but also with
cardiovascular diseases, diabetes mellitus and neurological, rheumatological and respiratory
disorders.
Polysomnography (a kind of sleep laboratory test)

Polysomnography is the continuous, attended, comprehensive recording of the biophysiological

changes that occur during sleep.

A polysomnogram is typically recorded at night and lasts between 6 and 8 hours.

Personality Disorders

The DSM-5 defines a general personality disorder as an enduring pattern of behavior and inner
experiences that deviates significantly from the individual's cultural standards; is rigidly pervasive;
has an onset in adolescence or early adulthood; is stable through time; leads to unhappiness and
impairment; and manifests in at least two of the following four areas:

cognition, affectivity, interpersonal function, or impulse control.

Personality disorder subtypes

The tree clusters are based on descriptive similarities.

Cluster A includes three personality disorders with odd, aloof features.

Cluster B includes four personality disorders with dramatic, impulsive, and erratic features.

Cluster C includes three personality disorders sharing anxious and fearful features.
Genetic Factors

Psychoanalytic

Internal object relations

Through identification, children internalize parents and others in such a way that the traits of the
external object are incorporated into the self and the child "owns" the traits.

These internal self-representations and object representations are crucial in developing the
personality and, through externalization and projective identification, are played out in
interpersonal scenarios in which others are coerced into playing a role in the person's internal life.

Paranoid personality disorder

 Persons with paranoid personality disorder are characterized by long-standing

suspiciousness and mistrust of persons in general.
 They refuse responsibility for their own feelings and assign responsibility to others.
 They are often hostile, irritable, and angry.
 Bigots, injustice collectors, pathologically jealous spouses often have paranoid personality
disorder.
 Ideas of reference and logically defended illusions are common.
 They lack warmth and are impressed with, and pay close attention to, power and rank. They
express disdain for those they see as weak, sickly, impaired, or in some way defective.
 

SCHIZOID PERSONALITY DISORDER

 Schizoid personality disorder is characterized by a lifelong pattern of social withdrawal.

 Persons with schizoid personality disorder are often seen by others as eccentric, isolated, or
lonely.
 Their discomfort with human interaction; their introversion; and their gentle, constricted
affect are noteworthy.
 Persons with the disorder tend to gravitate toward solitary jobs that involve little or no
contact with others. Many prefer night work to day work so that they need not deal with
many persons.
 They appear quiet, distant and unsociable. They may pursue their own lives with remarkably
little need or longing for emotional ties.
 The life histories of such persons reflect solitary interests and success at noncompetitive,
lonely jobs that others find difficult to tolerate.
 Their sexual lives may exist exclusively in fantasy, and they may postpone mature sexuality
indefinitely.


SCHIZOTYPAL PERSONALITY DISORDER

 Persons with schizotypal personality disorder are strikingly odd or strange.

 Magical thinking, peculiar notions, ideas of reference, illusions, and derealization are part of
a schizotypal person's everyday world.
 These patients may be superstitious or claim powers of clairvoyance and may believe that
they have other special powers of thought and insight

ANTISOCIAL PERSONALITY DISORDER

 Although characterized by continual antisocial or criminal acts, the disorder is not

synonymous with criminality.
 Patients with antisocial personality disorder can often seem to be normal and even charming
and ingratiating.
 Their histories, however, reveal many areas of disordered life functioning. Lying, truancy,
running away from home, thefts, fights, substance abuse, and illegal activities are typical
experiences that patients report as beginning in childhood.
 They are extremely manipulative and can frequently talk others into participating in
schemes for easy ways to make money or to achieve fame or notoriety.
 Disturbance (mess), spousal abuse, child abuse are common events in their lives. A notable
finding is a lack of remorse for these actions.
 

Borderline Personality Disorder

 Patients with borderline personality disorder stand on the border between neurosis and
psychosis, and they are characterized by extraordinarily unstable affect, mood, behavior,
object relations, and self-image.
 Persons with borderline personality disorder almost always appear to be in a state of crisis.
Mood swings are common. Patients can be argumentative at one moment, depressed the
next, and later complain of having no feelings.
 The behavior of patients with borderline personality disorder is highly unpredictable, and
their achievements are rarely at the level of their abilities.
 The painful nature of their lives is reflected in repetitive self destructive acts. Such patients
may slash their wrists and perform other self-mutilations to elicit help from others, to
express anger, or to nub themselves to overwhelming affect. Because they feel both
dependent and hostile, persons with this disorder have complex interpersonal
relationships.
 They can be dependent on those with whom they are close and, when frustrated, can
express enormous anger toward their intimate friends.
 Patients with borderline personality disorder cannot tolerate being alone, and they prefer a
frantic search for companionship, no matter how unsatisfactory, to their own company.
 They often complain about chronic feelings of emptiness and boredom and the lack of a
consistent sense of identity (identity diffusion); when pressed, they often complain about
how depressed they usually feel.
 

HISTRIONIC PERSONALITY DISORDER

Persons with histrionic personality disorder are excitable and emotional and behave in a colorful,
dramatic, extroverted fashion. Accompanying their flamboyant aspects, however, is often an
inability to maintain deep, long-lasting attachments.

Persons with histrionic personality disorder show a high degree of attention-seeking behavior. They
tend to exaggerate their thoughts and feelings and make everything sound more important than it
really is.

They may act on their sexual impulses to reassure themselves that they are attractive to the other
sex.

The major defenses of patients with histrionic personality disorder are repression and dissociation.
Accordingly, such patients are unaware of their true feelings and cannot explain their motivations.
 

NARCISSISTIC PERSONALITY DISORDER

 Persons with narcissistic personality disorder are characterized by a heightened sense of

self-importance, lack of empathy, and grandiose feelings of uniqueness. Underneath,
however, their self esteem is fragile and vulnerable to even minor criticism.
 They consider themselves special and expect special treatment. Their sense of entitlement
is striking.
 They handle criticism poorly and may become enraged when someone dares to criticize
them, or they may appear completely indifferent to criticism.
 Persons with this disorder want their own way and are frequently ambitious to achieve
fame and fortune.
 Interpersonal exploitiveness is commonplace. They cannot show empathy, and they feign
sympathy only to achieve their own selfish ends.

Obsessive-compulsive personality disorder

 Obsessive-compulsive personality disorder is characterized by emotional constriction,

orderliness, perseverance, stubbornness, and indecisiveness.
  The essential feature of the disorder is a pervasive pattern of perfectionism and inflexibility.
 Persons with obsessive-compulsive personality disorder are preoccupied with rules,
regulations, orderliness, neatness, details, and the achievement of perfection.
 Persons with obsessive-compulsive personality disorder have limited interpersonal skills.
 They are eager to please those whom they see as more powerful than they are, however,
and they carry out these persons' wishes in an authoritarian manner.
 The defense mechanisms they use are rationalization, isolation, intellectualization, reaction
formation, and undoing.

INTELLECTUALIZATION: A defense mechanism by which an individual deals with emotional conflict

or stressors by the excessive use of abstract thinking to control or minimize disturbing feelings.

For example, a man is involved in a car accident that causes him to be paralyzed. He spends hours in
the hospital brooding over the details of the accident and the treatment he has received in the
hospital but does so in an emotionally barren manner.

ISOLATION OF AFFECT: A defense mechanism by which an individual deals with emotional conflict or
stressors by separating ideas from the feelings originally associated with them. The individual loses
touch with the feelings associated with the given idea (eg, the traumatic event) although
remaining aware of the cognitive elements of it (eg, descriptive details).

For example, a man comes home to find his wife in bed with another man. Later, describing the scene
to a friend, the man can relate specific details of the scene but appears emotionally unmoved by the
whole event.

RATIONALIZATION: A defense mechanism by which an individual deals with emotional conflict or

stressors by concealing the true motivations for thoughts, actions, or feelings through the
elaboration of reassuring or self-serving but incorrect explanations.

For example, a woman steals a coat from a local department store although she can afford to pay for
it. She tells herself, “It’s okay—that department store has plenty of money, and they won’t miss one
coat!”

UNDOING: Undoing can be realistically or magically associated with the conflict and serves to reduce
anxiety and control the underlying impulse.

An example of undoing is seen in the child’s game in which one avoids stepping on cracks in the
sidewalk to avoid “breaking your mother’s back.”
DEPENDENT PERSONALITY DISORDER

Persons with dependent personality disorder subordinate their own needs to those of others, get
others to assume responsibility for major areas of their lives, lack self confidence, and may
experience intense discomfort when alone for more than a brief period.

The disorder has been called passive-dependent personality.

Freud described an oral-dependent personality dimension characterized by dependence, pessimism,

fear of sexuality, self-doubt, passivity, suggestibility.

Persons with the disorder cannot make decisions without an excessive amount of advice and
reassurance from others.

Because persons with the disorder do not like to be alone, they seek out others on whom they can
depend; their relationships, thus, are distorted by their need to be attached to another person.
AVOIDANT PERSONALITY DISORDER

 Persons with avoidant personality disorder show extreme sensitivity to rejection and may
lead socially withdrawn lives.
 Altough shy, they are not asocial and show a great desire for companionship, but they need
unusually strong guarantees of uncritical acceptance.
 Such persons are commonly described as having an inferiority complex.
 These persons desire the warmth and security of human companionship but justify their
avoidance of relationships by their fear of rejection. Because they are hypervigilant about
rejection, they are afraid to speak up in public or to make requests of others.