CHAPTER 8: EATING AND SLEEP- repeated vomiting, which gives

the face a chubby appearance.

WAKE DISORDERS
 Repeated vomiting also may
erode the dental enamel on the
inner surface of the front teeth as
EATING DISORDERS well as tear the esophagus. More
important, continued vomiting
Bulimia Nervosa - out-of-control eating
may upset the chemical balance
episodes, or binges, are followed by self-
of bodily fluids, including sodium
induced vomiting, excessive use of
and potassium levels. This
laxatives, or other attempts to purge (get
condition, called an electrolyte
rid of) the food.
imbalance.
 The hallmark of bulimia nervosa is  An individual with bulimia usually
eating a larger amount of food presents with additional
typically, more junk food than psychological disorders,
fruits and vegetables than most particularly anxiety and mood
people would eat under similar disorders.
circumstances.  One prominent theory suggested
 Just as important as the amount of that eating disorders are simply a
food eaten is that the eating is way of expressing depression. But
experienced as out of control. most evidence indicates that
 Another important criterion is that depression follows bulimia and
the individual attempts to may be a reaction to it.
compensate for the binge eating  Bulimia seems strongly related to
and potential weight gain, almost anxiety disorders and somewhat
always by purging techniques. less so to mood and substance
 Techniques include self-induced use disorders. Underlying traits of
vomiting immediately after emotional instability and novelty
eating, as in the case of Phoebe, seeking in these individuals may
and using laxatives (drugs that account for these patterns of
relieve constipation) and diuretics comorbidity.
(drugs that result in loss of fluids
Diagnostic Criteria for Bulimia Nervosa
through greatly increased
frequency of urination). A. Recurrent episodes of binge eating.
 Bulimia nervosa was subtyped in An episode of binge eating is
DSM-IV-TR into purging type (for characterized by both of the following:
example, vomiting, laxatives, or
1. Eating, in a discrete period of time
diuretics) or nonpurging type (for
(e.g., within any 2-hour period), an
example, exercise and/or
amount of food that is definitely larger
fasting).
than most people would eat during a
 Chronic bulimia with purging has
similar period of time under similar
a number of medical
circumstances.
consequences. One is salivary
gland enlargement caused by
2. A sense of lack of control over eating weight loss every day for weeks on
during the episode (e.g., a feeling that end is satisfactory.
one cannot stop eating or control what
Diagnostic Criteria for Anorexia
or how much one is eating).
Nervosa
B. Recurrent inappropriate
A. Restriction of energy intake relative
compensatory behaviors in order to
to requirements, leading to a
prevent weight gain, such as self-
significantly low body weight in the
induced vomiting; misuse of laxatives,
context of age, sex, developmental
diuretics, or other medications; fasting; or
trajectory, and physical health.
excessive exercise.
Significantly low weight is defined as
C. The binge eating and inappropriate a weight that is less than minimally
compensatory behaviors both occur, on normal or, for children and
average, at least once a week for 3 adolescents, less than that minimally
months. expected.

D. Self-evaluation is unduly influenced by B. Intense fear of gaining weight or of

body shape and weight. becoming fat, or persistent behavior
that interferes with weight gain, even
E. The disturbance does not occur
though at a significantly low weight.
exclusively during episodes of anorexia
nervosa. C. Disturbance in the way in which
one’s body weight or shape is
Anorexia Nervosa - the person eats only
experienced, undue influence of
minimal amounts of food or exercises
body weight or shape on self-
vigorously to offset food intake so body
evaluation, or persistent lack of
weight sometimes drops dangerously.
recognition of the seriousness of the
 Many individuals with bulimia current low body weight.
have a history of anorexia; that is,
Specify whether:
they once used fasting to reduce
their body weight below desirable Restricting type: During the past 3
levels. months, the individual has not
 Two subtypes of anorexia engaged in recurrent episodes of
nervosa. In the restricting type, binge eating or purging behavior
individuals diet to limit calorie (i.e., self-induced vomiting or the
intake; in the binge - eating - misuse of laxatives, diuretics, or
purging type, they rely on purging. enemas). This subtype describes
 Individuals with anorexia are presentations in which weight loss is
never satisfied with their weight accomplished primarily through
loss. Staying the same weight dieting, fasting, and/or excessive
from one day to the next or exercise.
gaining any weight is likely to
Binge-eating/purging type: During
cause intense panic, anxiety, and
the past 3 months, the individual has
depression. Only continued
engaged in recurrent episodes of
 binge eating or purging behavior Diagnostic Criteria for Binge-Eating
(i.e., self-induced vomiting or the Disorder
misuse of laxatives, diuretics, or
A. Recurrent episodes of binge eating.
enemas).
An episode of binge eating is
 One common medical characterized by both of the following:
complication of anorexia nervosa
1. Eating, in a discrete period of time
is cessation of menstruation
(e.g., within any 2-hour period), an
(amenorrhea), which also occurs
amount of food that is definitely larger
relatively often in bulimia.
than what most people would eat in a
 As with bulimia nervosa, anxiety
similar period of time under similar
disorders and mood disorders are
circumstances.
often present in individuals with
anorexia. 2. A sense of lack of control over eating
 One anxiety disorder that seems during the episode (e.g., a feeling that
to co-occur often with anorexia is one cannot stop eating or control what
obsessive-compulsive disorder or how much one is eating).
(OCD).
B. The binge-eating episodes are
Lanugo - downy hair on the limbs and associated with three (or more) of the
cheeks. following:
Binge-eating Disorder - individuals may 1. Eating much more rapidly than
binge repeatedly and find it distressing, normal.
but they do not attempt to purge the
food. 2. Eating until feeling uncomfortably full.

 Many cases of anorexia and BED, 3. Eating large amounts of food when not
but not bulimia, begin after age feeling physically hungry.
18. 4. Eating alone because of feeling
 The median age of onset for all embarrassed by how much one is
eating-related disorders occurred eating.
in a narrow range of 18 to 21
years. 5. Feeling disgusted with oneself,
 For anorexia, this age of onset was depressed, or very guilty afterward.
fairly consistent, with younger C. Marked distress regarding binge
cases tending to begin at age 15, eating is present.
but it was more common for cases
of bulimia to begin as early as age D. The binge eating occurs, on average,
10. at least once a week for 3 months.
 The chief characteristic of these
E. The binge eating is not associated with
and related disorders is an
the recurrent use of inappropriate
overwhelming, all-encompassing
compensatory behavior as in bulimia
drive to be thin.
nervosa and does not occur exclusively
during the course of bulimia nervosa or with one’s body, is a primary risk
anorexia nervosa. factor for later eating disorders.
 In other words, a person might
Avoidant/Restrictive Food Intake
inherit a tendency to be
Disorder (ARFID) - people with this
emotionally responsive to stressful
problem limit their food intake not
life events and, as one
because they are concerned about
consequence, might eat
weight or body shape but because they
impulsively in an attempt to
are simply not interested in eating or
relieve stress and anxiety.
food or because they avoid certain
 Biological processes are quite
sensory characteristics or consequences
active in the regulation of eating
of food or eating.
and thus of eating disorders, and
 Body mass index (BMI), which is substantial evidence points to the
highly correlated with body fat. hypothalamus as playing an
 Obesity is a significant health important role. Investigators have
problem because the more studied the hypothalamus and
overweight someone is at a given the major neurotransmitter
height, the greater the risks to systems: including
health, norepinephrine, dopamine, and,
 Obesity is comorbid with diabetes particularly, serotonin - that pass
(which it often is), a condition so through it to determine whether
common and concerning that it something is malfunctioning when
has become known as diabesity. eating disorders occur.
 Strong associations between
CAUSES ovarian hormones and
 Anorexia and particularly bulimia dysregulated or impulsive eating
are the most culturally specific in women prone to binge-eating
psychological disorders yet episodes.
identified. For young women in  The strong association between
competitive environments, self- the onset of bulimia and puberty,
worth, happiness, and success speculate that the onset of
are largely determined by body puberty and associated
measurements and percentage hormonal changes may “turn on”
of body fat, factors that have little certain hormone responsive risk
or no correlation with personal genes in women prone to binge
happiness and success in the long eating to begin with because
run. The cultural imperative for they possess these genetic
thinness directly results in dieting, patterns.
the first dangerous step down the  Clinical observations over the
slippery slope to anorexia and years have indicated that many
bulimia. young women with eating
 Dieting is one factor that can disorders have a diminished sense
contribute to eating disorders of personal control and
and, along with dissatisfaction confidence in their own abilities
 and talents. This may manifest as  Early studies adapting CBT for
strikingly low self esteem. They also bulimia to obese binge eaters
display more perfectionistic were quite successful.
attitudes, perhaps learned or  In contrast to results with bulimia, it
inherited from their families, which appears that IPT is every bit as
may reflect attempts to exert effective as CBT for binge eating.
control over important events in  In this regard, effective treatments
their lives. for restricting anorexics are similar
 Perfectionism alone, however, is to those for patients with bulimia
only weakly associated with the nervosa, particularly in the
development of an eating “transdiagnostic” approach (CBT-
disorder because individuals must E).
consider themselves overweight  Although there is not a single
and manifest low self-esteem treatment of choice, a family
before the trait of perfectionism focused approach can often be
makes a contribution. beneficial for a number of
 In any case, it is clear that social reasons.
and cultural pressures to be thin
Cognitive-Behavioral Therapy Enhanced
motivate significant restriction of
(CBT-E) - the principal focus of this
eating, usually through severe
protocol is on the distorted evaluation of
dieting.
body shape and weight and on
TREATMENT maladaptive attempts to control weight
in the form of strict dieting (possibly
 In addition, as you will see, drug accompanied by binge eating) and
and psychological treatments methods to compensate for overeating
with proven effectiveness for (such as purging and laxative misuse).
anxiety disorders are also the
treatments of choice for eating  The first stage is teaching the
disorders. patient the physical
 One definitive study reported that consequences of binge eating
fluoxetine (Prozac) had no benefit and purging, as well as the
in preventing relapse in patients ineffectiveness of vomiting and
with anorexia after weight has laxative abuse for weight control.
been restored. On the other  CBT-E focuses on altering
hand, there is some evidence that dysfunctional thoughts and
drugs may be useful for some attitudes about body shape,
people with bulimia, particularly weight, and eating.
during the bingeing and purging
“Failure to Thrive” Syndrome - in which
cycle. The drugs generally
growth and development are severely
considered the most effective for
stunted because of inadequate
bulimia are the same
nutrition.
antidepressant medications
proven effective for mood Reverse Anorexia Nervosa - men with this
disorders and anxiety disorders. syndrome reported they were extremely
concerned about looking small, even the surgical approach to extreme
though they were muscular. obesity called bariatric surgery
 Currently, the FDA has only a few
OBESITY approved drugs approved for this
 There are two forms of purpose, such as lorcaserin
maladaptive eating patterns in (Belviq) and
people who are obese. The first is phentermine/topiramate
binge eating, and the second is (Osymia).
night eating syndrome.  Kelly Brownell, now professor and
dean of the School of Public
Nocturnal Eating Syndrome - In this Policy at Duke University,
condition, individuals get up during the proposed in the New York Times
night and raid the refrigerator but never that we should consider taxing
wake up. They also may eat uncooked high-calorie, high-fat, orhigh-
or other dangerous foods while asleep. sugar foods as a means of
Night Eating Syndrome - the individuals addressing the obesity epidemic.
are awake as they go about their nightly This proposal sparked a firestorm
eating patterns. It is an important target of controversy and came to be
for treatment in any obesity program to known as the “Twinkie tax.”
reregulate patterns of eating so that SLEEP DISORDERS
individuals eat more during the day,
when their energy expenditure is highest. REM Sleep – also known as dream sleep.

 Henderson and Brownell (2004)  CBT improved symptoms among

make a point that this obesity a group of depressed men and
epidemic is clearly related to the normalized REM sleep patterns.
spread of modernization. In other
Chronotype - whether you are a morning
words, as we advance
or evening type, is regulated by both
technologically, we are getting
your circadian clock and genetic
fatter.
variations in the clock genes and the
 Treatment is usually organized in a
environment.
series of steps from least intrusive
to most intrusive depending on Social Jetlag - switching your schedule
the extent of obesity. The first step because of social factors is similar to
is usually a self-directed weight- changing time zones when you travel.
loss program in individuals who
 Sleep–wake disorders are divided
buy a popular diet book. The next
into two major categories:
step is commercial self-help
dyssomnias and parasomnias.
programs such as Weight
Watchers and Jenny Craig. The Dyssomnias – involve difficulties in
most successful programs are getting enough sleep, problems with
professionally directed behavior sleeping when you want to and
modification programs. Finally, complaints about the quality of sleep,
such as not feeling refreshed even Diagnostic Criteria for Insomnia Disorder
though you have slept the whole night.
A. A predominant complaint of
Parasomnias - are characterized by dissatisfaction with sleep quantity or
abnormal behavioral or physiological quality, associated with (one or more) of
events that occur during sleep, such as the following symptoms:
nightmares and sleepwalking.
1. Difficulty initiating sleep. (In children,
Polysomnographic (PSG) Evaluation - the this may manifest as difficulty initiating
patient spends one or more nights sleep without caregiver intervention.)
sleeping in a sleep laboratory and being
2. Difficulty maintaining sleep,
monitored on a number of measures,
characterized by frequent awakenings
including respiration and oxygen
or problems returning to sleep after
desaturation (a measure of airflow); leg
awakenings. (In children, this may
movements; brain wave activity,
manifest as difficulty returning to sleep
measured by an
without caregiver intervention.)
electroencephalogram; eye
movements, measured by an 3. Early-morning awakening with inability
electrooculogram; muscle movements, to return to sleep.
measured by an electromyogram;
and heart activity, measured by an B. The sleep disturbance causes clinically
electrocardiogram. significant distress in social,
occupational, educational, academic,
Actigraph - This instrument records the behavioral, or other important areas of
number of arm movements and the data functioning.
can be downloaded to a computer to
determine the length and quality of C. The sleep difficulty occurs at least 3
sleep. nights per week.

Sleep Efficiency (SE) - the percentage of D. The sleep difficulty is present for at
time actually spent asleep, not just lying least 3 months.
in bed trying to sleep. SE is calculated by E. The sleep difficulty occurs despite
dividing the amount of time sleeping by adequate opportunity for sleep.
the amount of time in bed.
F. The insomnia is not better explained by
Insomnia - to mean “not sleeping,” it and does not occur exclusively during
actually applies to a number of the course of another sleep–wake
complaints. People are considered to disorder (e.g., narcolepsy, a breathing-
have insomnia if they have trouble falling related sleep disorder, a circadian
asleep at night (difficulty initiating sleep), rhythm sleep–wake disorder, a
if they wake up frequently or too early parasomnia).
and can’t go back to sleep (difficulty
maintaining sleep), or even if they sleep G. The insomnia is not attributable to the
a reasonable number of hours but are still physiological effects of a substance
not rested the next day (nonrestorative (e.g., a drug of abuse, a medication).
sleep).
H. Coexisting mental disorders and withdrawn. This rebound leads people to
medical conditions do not adequately think they still have a sleep problem,
explain the predominant complaint of readminister the medicine, and go
insomnia. through the cycle repeatedly. In other
words, taking sleep aids can perpetuate
Specify if:
sleep problems.
Episodic: Symptoms last at least 1 month
Hypersomnolence Disorders - involve
but less than 3 months
sleeping too much (hyper means “in
Persistent: Symptoms last 3 months or great amount” or “abnormal excess”).
longer
Diagnostic Criteria for Hypersomnolence
Recurrent: Two (or more) episodes within Disorder
the space of 1 year
A. Self-reported excessive sleepiness
 Insomnia accompanies many (hypersomnolence) despite a main sleep
medical and psychological period lasting at least 7 hours, with at
disorders, including pain and least one of the following symptoms:
physical discomfort, physical
1. Recurrent periods of sleep or lapses
inactivity during the day, and
into sleep within the same day.
respiratory problems. Sometimes
insomnia is related to problems 2. A prolonged main sleep episode of
with the biological clock and its more than 9 hours per day that is
control of temperature. nonrestorative (i.e., unrefreshing).

Sleep Apnea - a sleeping disorder that 3. Difficulty being fully awake after
involves obstructed nighttime breathing. abrupt awakening.

Periodic Limb Movement Disorder – a B. The hypersomnolence occurs at least

sleeping disorder with excessive jerky leg three times per week, for at least 3
movements. months.

 An integrative view of sleep C. The hypersomnolence is

disorders includes several accompanied by significant distress or
assumptions. The first is that, at impairment in cognitive, social,
some level, both biological and occupational, or other important areas
psychological factors are present of functioning.
in most cases. A second
D. The hypersomnolence is not better
assumption is that these multiple
explained by and does not occur
factors are reciprocally related.
exclusively during the course of another
Jet Lag - in which people’s sleep patterns sleep disorder (e.g., narcolepsy,
are disrupted, sometimes seriously, when breathing-related sleep disorder,
they fly across several time zones. circadian rhythm sleep–wake disorder,
or a parasomnia).
Rebound Insomnia - where sleep
problems reappear, sometimes worse E. The hypersomnolence is not
may occur when the medication is attributable to the physiological
effects of a substance (e.g., a drug of strong emotion such as anger or
abuse, a medication). happiness.

F. Coexisting mental and medical Sleep Paralysis - a brief period after

disorders do not adequately explain the awakening when they can’t move or
predominant complaint of speak that is often frightening to those
hypersomnolence. who go through it.

Specify if: Hypnagogic Hallucinations - vivid and

often terrifying experiences that begin at
Acute: Duration of less than 1 month
the start of sleep and are said to be
Subacute: Duration of 1–3 months unbelievably realistic because they
include not only visual aspects but also
Persistent: Duration of more than 3 touch, hearing, and even the sensation
months of body movement.
Specify current severity: Specify severity Diagnostic Criteria for Narcolepsy
based on degree of difficulty
maintaining daytime alertness as A. Recurrent periods of irrepressible need
manifested by the occurrence of to sleep, lapsing into sleep, or napping
multiple attacks of irresistible sleepiness occurring within the same day. These
within any given day occurring, for must have been occurring at least three
example, while sedentary, driving, times per week over the past 3 months.
visiting with friends, or working.
B. The presence of at least one of the
Mild: Difficulty maintaining daytime following:
alertness 1–2 days/week
1. Episodes of cataplexy defined as
Moderate: Difficulty maintaining either (a) or (b), occurring at least a few
daytime alertness 3–4 days/week times per month:

Severe: Difficulty maintaining daytime (a) In individuals with long-standing

alertness 5–7 days/week disease, brief (seconds to minutes)
episodes of sudden bilateral loss of
Narcolepsy - sudden and irresistible sleep muscle tone with maintained
attacks. consciousness, precipitated by laughter
 In addition to daytime sleepiness, or joking.
some people with narcolepsy (b) In children or in individuals within 6
experience cataplexy, a sudden months of onset, spontaneous grimaces
loss of muscle tone. It occurs while or jaw-opening episodes with tongue
the person is awake and can thrusting or a global hypotonia, without
range from slight weakness in the any obvious emotional triggers.
facial muscles to complete
physical collapse. It lasts from 2. Hypocretin deficiency, as measured
several seconds to several using cerebrospinal fluid (CSF)
minutes; it is usually preceded by hypocretin-1 immunoreactivity values
(less than or equal to one third of values
obtained in healthy subjects tested using narcolepsy. These neurons create
the same assay or less than or equal to peptides that appear to play an
110 pg/mL). Low CSF levels of important role in wakefulness,
hypocretin-1 must not be observed in the although why these individuals
context of acute brain injury, lack just these specific neurons is
inflammation or infection. not yet understood.

3. Nocturnal sleep polysomnography Breathing-related Sleep Disorders -

showing rapid eye movement (REM) people whose breathing is interrupted
sleep latency less than or equal to 15 during their sleep often experience
minutes, or a multiple sleep latency test numerous brief arousals throughout the
showing a mean sleep latency less than night and do not feel rested even after 8
or equal to 8 minutes and two or more or 9 hours asleep.
sleep onset REM periods.
 Breathing is constricted a great
Specify current severity: deal and may be labored
(hypoventilation).
Mild: Need for naps only once or twice
per day. Sleep disturbance, if present, is Diagnostic Criteria for Obstructive Sleep
mild. Cataplexy, when present, is Apnea Hypopnea
infrequent (occurring less than once per
A. Either (1) or (2):
week).
1. Evidence by polysomnography of at
Moderate: Need for multiple naps daily.
least five obstructive apneas or
Sleep may be moderately disturbed.
hypopneas per hour of sleep and either
Cataplexy, when present, occurs daily or
of the following sleep symptoms:
every few days.
(a) Nocturnal breathing disturbances:
Severe: Nearly constant sleepiness and,
snoring, snorting/ gasping, or breathing
often, highly disturbed nocturnal sleep
pauses during sleep.
(which may include excessive body
movement and vivid dreams). (b) Daytime sleepiness, fatigue, or
unrefreshing sleep despite sufficient
Cataplexy, when present, is drug-
opportunities to sleep that is not better
resistant, with multiple attacks daily.
explained by another mental disorder
 Sleep paralysis commonly co- (including a sleep disorder) and is not
occurs with anxiety disorders, in attributable to another medical
which case the condition is condition.
termed isolated sleep paralysis.
2. Evidence by polysomnography of 15
 Narcolepsy is associated with a
or more obstructive apneas and/or
cluster of genes on chromosome
hypopneas per hour of sleep regardless
6, and it may be an autosomal
of accompanying symptoms.
recessive trait. It appears that
there is a significant loss of a Specify current severity:
certain type of nerve cell
(hypocretin neurons) in those with Mild: Apnea hypopnea index is less than
15
Moderate: Apnea hypopnea index is 15– abnormalities during wakefulness is an
30 indicator of greater severity.

Severe: Apnea hypopnea index is Obstructive Sleep Apnea Hypopnea

greater than 30 Syndrome - occurs when airflow stops
despite continued activity by the
Diagnostic Criteria for Central Sleep
respiratory system.
Apnea
Central Sleep Apnea - involves the
A. Evidence by polysomnography of five
complete cessation of respiratory
or more central apneas per hour of
activity for brief periods and is often
sleep.
associated with certain central nervous
B. The disorder is not better explained by system disorders, such as cerebral
another current sleep disorder. vascular disease, head trauma, and
degenerative disorders.
Specify current severity:
Sleep-related Hypoventilation - is a
Severity of central sleep apnea is graded decrease in airflow without a complete
according to the frequency of the pause in breathing. This tends to cause
breathing disturbances as well as the an increase in carbon dioxide (CO2)
extent of associated oxygen levels because insufficient air is
desaturation and sleep fragmentation exchanged with the environment.
that occur as a consequence of
repetitive respiratory disturbances. Circadian Rhythm Sleep Disorder - is
characterized by disturbed sleep (either
Diagnostic Criteria for Sleep-Related insomnia or excessive sleepiness during
Hypoventilation the day) brought on by the brain’s
A. Polysomnography demonstrates inability to synchronize its sleep patterns
episodes of decreased respiration with the current patterns of day and
associated with elevated CO2 levels. night.
(Note: In the absence of objective  Our brains have a mechanism
measurement of CO2, persistent low that keeps us in sync with the
levels of hemoglobin oxygen saturation outside world. Our biological
unassociated with apneic/ hypopneic clock is in the suprachiasmatic
events may indicate hypoventilation.) nucleus in the hypothalamus.
B. The disorder is not better explained by Jet lag type - as its name implies, caused
another current sleep disorder. by rapidly crossing multiple time zones.
Specify current severity: People with jet lag usually report difficulty
going to sleep at the proper time and
Severity is graded according to the feeling fatigued during the day.
degree of hypoxemia and hypercarbia
present during sleep and evidence of Shift Work Type Sleep Problems - are
end organ impairment due to these associated with work schedules. Many
abnormalities (e.g., right-sided heart people, such as hospital employees,
failure). The presence of blood gas police, or emergency personnel, work at
night or must work irregular hours; as a cycle with later and later bedtimes
result, they may have problems sleeping ultimately going throughout the day.
or experience excessive sleepiness
Melatonin - contributes to the setting of
during waking hours.
our biological clocks that tell us when to
Diagnostic Criteria for Circadian Rhythm sleep. It has been nicknamed the
Sleep–Wake Disorders “Dracula hormone” because its
production is stimulated by darkness and
A. A persistent or recurrent pattern of
ceases in daylight.
sleep disruption that is primarily due to an
alteration of the circadian system or to a  Perhaps the most common
misalignment between the endogenous treatments for insomnia are
circadian rhythm and the sleep–wake medical. People who complain of
schedule required by an individual’s insomnia to a medical
physical environment or social or professional are likely prescribed
professional schedule. one of several benzodiazepine or
related medications which
B. The sleep disruption leads to excessive
include short-acting drugs such as
sleepiness or insomnia, or both.
triazolam (Halcion), zaleplon
C. The sleep disturbance causes (Sonata), and zolpidem (Ambien)
clinically significant distress or and long-acting drugs such as
impairment in social, occupational, and flurazepam (Dalmane).
other important areas of functioning.  Short acting drugs (those that
cause only brief drowsiness) are
Specify if: preferred, because the long-
Episodic: Symptoms last at least 1 month acting drugs sometimes do not
but less than 3 months stop working by morning and
people report more daytime
Persistent: Symptoms last 3 months or sleepiness.
longer  The long-acting medications are
Recurrent: Two or more episodes occur sometimes preferred when
within the space of 1 year negative effects such as daytime
anxiety are observed in people
Delayed Sleep Phase Type - where sleep taking the short-acting drugs.
is delayed or there is a later than normal  Newer medications,such as those
bedtime. that work directly with the
melatonin system (for example,
Advanced Sleep Phase Type - are “early
ramelteon [Rozerem]), are also
to bed and early to rise.
being developed to help people
Irregular Sleep–wake Type – people who fall and stay asleep.
experience highly varied sleep cycles.  To help people with
hypersomnolence or narcolepsy,
Non-24-hour Sleep–wake Type - (for
physicians usually prescribe a
example, sleeping on a 25- or 26-hour
stimulant such as
methylphenidate (Ritalin, the
 medication Hoa was taking) or with circadian rhythm problems
modafinil. readjust their sleep patterns.
 Cataplexy, or loss of muscle tone,  Relaxation treatments reduce the
can be treated with physical tension that seems to
antidepressant medication, not prevent some people from falling
because people with narcolepsy asleep at night.
are depressed but because  Cognitive treatment may also
antidepressants suppress REM (or focus on worries about sleep itself,
dream) sleep. Also, sodium such as by helping patients to
oxybate is recommended to treat change their assumptions that
cataplexy. they cannot function well on little
 Treatment of breathing-related sleep, which can trigger anxiety
sleep disorders focuses on helping that disrupts falling asleep,
the person breathe better during  Progressive relaxation or sleep
sleep. For some, this means hygiene (changing daily habits
recommending weight loss. that may interfere with sleep),
 The gold standard for the
Disorder of Arousal - includes a number
treatment of obstructive sleep
of motor movements and behaviors
apnea involves the use of a
during NREM sleep such as sleepwalking,
mechanical device called the
sleep terrors, and incomplete
continuous positive air pressure
awakening.
(CPAP) machine.
 An interesting treatment for Sleep Terrors - which most commonly
people with mild apnea was afflict children, usually begin with a
developed by researchers in piercing scream. The child is extremely
collaboration with a Swiss upset, often sweating, and frequently
didgeridoo instructor. A has a rapid heartbeat. On the surface,
didgeridoo is a long instrument sleep terrors appear to resemble
constructed from tree limbs nightmares—the child cries and appears
hollowed out by termites. frightened—but they occur during NREM
 One general principle for treating sleep and therefore are not caused by
circadian rhythm disorders is that frightening dreams.
phase delays (moving bedtime
later) are easier than phase  One approach to reducing
advances (moving bedtime chronic sleep terrors is the use of
earlier). scheduled awakenings. Parents
 Another strategy to help people of children who were
with sleep problems involves using experiencing almost nightly sleep
bright light to trick the brain into terrors to awaken their child briefly
readjusting the biological clock. approximately 30 minutes before
 Research indicates that bright a typical episode (these usually
light (also referred to as occur around the same time
phototherapy) may help people each evening). This simple
technique, which was faded out
 over several weeks, was F. Coexisting mental and medical
successful in almost eliminating disorders do not explain the episodes of
these disturbing events. sleepwalking or sleep terrors.

Diagnostic Criteria for Nonrapid Eye  Sleepwalking (also called

Movement Sleep Arousal Disorders somnambulism) occurs during
NREM sleep.
A. Recurrent episodes of incomplete
awakening from sleep usually occurring Nocturnal Eating Syndrome - is when
during the first third of the major sleep individuals rise from their beds and eat
episode, accompanied by either one of while they are still asleep.
the following:
Sexsomnia - acting out sexual behaviors
1. Sleepwalking: Repeated episodes of such as masturbation and sexual
rising from bed during sleep and walking intercourse with no memory of the event.
about. While sleepwalking, the person
Diagnostic Criteria for Nightmare
has a blank, staring face; is relatively
Disorder
unresponsive to the efforts of others to
communicate with him or her; and can A. Repeated occurrences of extended,
be awakened only with great difficulty. extremely dysphoric, and well-
remembered dreams that usually involve
2. Sleep terrors: Recurrent episodes of
efforts to avoid threats to survival,
abrupt terror arousals from sleep, usually
security, or physical integrity and that
beginning with a panicky scream. There
generaly occur during the second half of
is intense fear and signs of autonomic
the major sleep episode.
arousal, such as mydriasis, tachycardia,
rapid breathing, and sweating, during B. On awakening from the dysphoric
each episode. There is relative dreams, the individual rapidly becomes
unresponsiveness to efforts of others to oriented and alert.
comfort the individual during the
episodes. C. The sleep disturbance causes
clinically significant distress or
B. No or little (e.g., only a single-visual- impairment in social, occupational, or
scene) dream imagery is recalled. other important areas of functioning.
C. Amnesia for the episodes is present. D. The nightmare symptoms are not
attributable to the physiological effects
D. The episodes cause clinically
of a substance (e.g., a drug of abuse, a
significant distress or impairment in social,
medication).
occupational, or other important areas
of functioning. E. Coexisting mental and medical
disorders do not adequately explain the
E. The disturbance is not attributable to
predominant complaint of dysphoric
the physiological effects of a substance
dreams.
(e.g., a drug of abuse, a medication).
Specify current severity:
Severity can be rated by the frequency (e.g., a drug of abuse, a medication) or
with which the nightmares occur: another medical condition.

Mild: Less than one episode per week on G. Coexisting mental and medical
average disorders do not explain the episodes.

Moderate: One or more episodes per

week but less than nightly

Severe: Episodes nightly

Diagnostic Criteria for Rapid Eye

Movement Sleep Behavior Disorder

A. Repeated episodes of arousal during

sleep associated with vocalization
and/or complex motor behaviors.

B. These behaviors arise during rapid eye

movement (REM) sleep and therefore
usually occur more than 90 minutes after
sleep onset, are more frequent during
the later portions of the sleep period, and
uncommonly occur during daytime
naps.

C. Upon awakening from these episodes,

the individual is completely awake, alert,
and not confused or disoriented.

D. Either of the following:

1. REM sleep without atonia on

polysomnographic recording.

2. A history suggestive of REM sleep

behavior disorder and an established
synucleinopathy diagnosis (e.g.,
Parkinson’s disease, multiple system
atrophy).

E. The behaviors cause clinically

significant distress or impairment in social,
occupational, or other important areas
of functioning (which may include injury
to self or the bed partner).

F. The disturbance is not attributable to

the physiological effects of a substance