Learning Unit 5

Disorders of Neuro-vegetative Function

Theme 1: Feeding Disorders

Listed Feeding Disorders

• PICA
Persistently eating one or more non-nutritive, non-food substances for at least a month
• Rumination Disorder
Repeated regurgitation of food after feeding or eating
• Avoidant/Restrictive Food Intake Disorder
Repeated avoidance of or limiting the intake of food during feeding or eating found in infants
or childhood
• Persistent disturbances to feeding and associated behaviours
• This maladaptive pattern is key in diagnosing these disorders
• These cause significant impairments to bodily and psychological functioning
• Feeding and eating disorders are very different
• Feeding disorders are more often found in children and are usually about the food itself
• An eating disorder is found in adolescents and upwards and is more about what the food
represents

PICA

• Changes in hormones and nutrient deficiencies cause cravings for strange foods or appetite
changes
• This behaviour is normal but forms the basis of Pica
• Non-food materials include ice, starch, clay, chalk, paint, paper, soap, string, soil, faeces,
hair, etc.
• Intestinal obstructions caused by hair are called trichobezars
• Prevalence rates are unknown but gender ratios appear to be equal
• Pica is most often found in childhood but can occur at any age
• Pregnancy can cause pica-like behaviour but is only a diagnosable problem if it causes
physical harm
• Many cultural or religious practices include the consumption of non-nutritive or non-food
substances and thus is not a disorder
• Pica is more often found in people with intellectual and behavioural impairments
• Chronically, pica represents a serious health concern
• Often resulting in nutritional deficiencies, poisoning, intestinal obstructions and infections
Rumination Disorder

• Ruminate literally means to chew the cud

• This is what cattle do when they partly chew and store food, then regurgitate to re-chew again
later
• Without any nausea, retching or disgust, the person will bring up partly digested food into the
mouth to rechew it
• Sometimes this partially digested food will be ejected from the mouth
• This most often presents in patients with severe mental: Retardation
• Some infants do this between 3 and 12 months and is not unusual
• Lack of stimulation, parental neglect and other early life stressors are implicated in its onset
• Malnutrition and social exclusion are serious complications of this disorder
• Physical illness that because regurgitation must be ruled out
• Bulimia nervosa and anorexia nervosa with purging behaviour are differential diagnoses
Avoidant/Restrictive Food Intake Disorder

• In this case, food (or certain foods) is avoided at all costs or the intake is severely limited
• We’re not talking about avoiding mushrooms on a pizza
• This avoidance/restriction is enough to cause nutrition issues, extreme distress when not
avoided or other complications
• Some children are particularly averse to the sensory quality or certain foods
• Appearance, smell, colour, texture, taste, etc.
• Children with autism who have heightened sensory awareness display this kind of behaviour
• Autistic spectrum disorders, AHD, OCD and anxiety disorders increase the risk of this
disorder
• Consequences include weight loss, failure to thrive, nutritional deficiencies, dependence on
supplements and lack of meeting developmental milestones
• Infants will appear fussy or apathetic to food and related behaviour

Theme 2: Eating Disorders

Listed Eating Disorders

• Anorexia Nervosa
Recurrent food refusal, leading to dangerously low body weight couple with a distorted body
image
• Bulimia Nervosa
Recurrent episodes of uncontrolled excessive binge eating, followed by compensatory actions
to reduce the caloric or energy impact of the food or to rid the body of the food itself
• Binge-Eating Disorder
Pattern of eating involving distress-inducing binges, not followed by purging behaviours
• Binge
A relatively brief episode of uncontrolled, excessive consumption – usually of food or alcohol
• Purge
Self-induced compensatory behaviours for excessive food ingestion

Scope and Severity of Eating Disorders

• During the 1950 and 1960s, we became more aware of the clinical significance of eating
disorders
• Eating disorders are widespread across the globe and increased significantly in developed
• counties from 1950 to now, this increase has levelled out somewhat
• All eating disorders are characterised by an overwhelming and all-encompassing drive to
attain and maintain a low weight and be thin
• How this drive manifest differentiates between the disorders?
• The risk of dying from an eating disorder is 6 times higher than the general population
• There are higher prevalence rates for people born between 1972 and 1985
• Especially for bulimia
• Recently there are earlier ages of onset for anorexia and bulimia
• Until recently, eating disorders were not found in developing countries
• The prevalence rate in developing countries is matching developed countries
• More than 90% of severe cases involve young females in competitive environments
• Many of these young women find each other online in order to support, educate and inspire
others in disordered eating (pro-ana and pro-mia websites)
Anorexia Nervosa (AN)

• Up to 20% of patients will die as a result of this disorder

• Anorexia has the highest mortality of ALL mental disorders
• Including suicide from depression and substance-related deaths
• Between 20% and 30% of anorexia-related deaths are suicides
• Deaths also result from severe medical complications resulting from the behaviour
• Patients have a morbid fear of gaining weight and losing control and overeating
• The major difference of AN with BN is the significant weight loss
• Both disorders have similar behaviours
• Patients are often proud of their diets and excessive control
• There is an obsessive drive for thinness
• AN is well publicised in the celebrity and modelling world but it is less common than BN
• Most commonly begins in adolescents who are overweight or thinks they are overweight
• They then start to diet with transforms into obsessiveness and morbid fears of gaining weight
• Severe, almost punitive, exercise is common
• Dramatic weight loss is due to extreme
caloric restriction
• This is sometimes combined with purging
activities
• In the purging type: purging happens more
frequently and the binging is relatively small in
comparison to BN
• Almost half of people with AN will have this
subtype
• The subtypes do not indicate severity but
just behaviour
• Maintaining or gaining weight causes
extreme anxiety, panic and depression
• Only sustained weight loss causes
satisfaction
• Significantly low body weight is 15% what is
expected according to BMI calculations
• Treatment is only sought when patients are
25% to 30% below
• The body image distortions can be likened to
body dysmorphic proportions

• Treatment is rarely their own decision and they tend to manipulate clinicians
• Odd behaviours surrounding food sometimes develop
• Becoming expert chefs
• Hoarding food in their rooms to look at
• Becoming interested in the food making process

Complications of Anorexia Nervosa

• Physical complications arise due to:

Nutritional deficiencies, chronic catabolism (the breakdown of the body), metabolic and
electrolyte disturbances, physical wasting, surgical complications and oesophageal ruptures
• This can cause organs to stop working, such as heart attacks, heart arrhythmias, or the lethal
shutting down of kidneys
• Amenorrhea – when the period stops
• Fat is needed for the production and maintenance of sex hormones
• This used to be a diagnostic criterion but does not happen in all patients
• Other medical signs and symptoms:
 • Dry skin, brittle hair or nails, sensitivity to cold, lanugo (downy hair on the limbs and cheeks),
chronically low blood pressure and heart rate, and many others
• Anxiety and depressive disorders are common comorbidities
• Up to 71% have had an MDD episode at least once
• There are similarities with OCD
• The obsessive thoughts followed by the ritualistic and compulsive behaviours
• Substance abuse is common too
• This is usually a strong predictor of mortality and suicide

AN Specific Treatment Considerations

• The most important goal is to restore body weight to at least low-to-normal range
• Inpatient treatment is often used, especially when the patient is non-compliant
• Tara Hospital in Joburg is the local go-to
• Weight gain initially is usually the easiest part of treatment
• Patients know they cannot be discharged until they gain weight
• Sometimes up to 500g per day
• Psychoeducation and nutritional counselling is used to promote healthy eating
• Patients will almost always relapse if there is no focus on underlying dysfunctional attitudes
about body weight and interpersonal disruptions
• Nutritional counselling is not enough
• For restrictive AN – focus on anxiety of obesity, fear of losing control and thinking thinness
means self-worth, success and happiness
• The family is vital in successful treatment
• Dysfunctional communication about food and eating is targeted
• Body-image distortions are worked through in family therapy
• The earlier treatment is started, the better the outcomes and chance of remission

Bulimia Nervosa (BN)

• Whilst people with AN are proud, people with BN are often

shameful and hide their eating issues and “lack of control”
• Many people with BN have a history of AN too
• This is a common disorder on Western university campuses
• The hallmark is eating a larger amount of food (usually high
energy, easily palatable) than most people would in a time
period
• This eating is experienced as out of control
• This purging is then compensated for diuretics because urine
output to increase which promotes water loss
• Some patients will use diet restriction medications and thyroid
medications
• Patients with BN may exercise and fast for long periods of time
• This is similar to AN but is less severe
• It is also followed by a large binge unlike AN when binges are
small
• They often have BPD features
• Mood lability, erratic behaviour, pervasive anxiety, turbulent
interpersonal relationships and self-harm
• Some patients experience amenorrhea too
• Purging is not actually an effective way to restrict caloric intake
• It only results in 50% reduced caloric intake, less if it is delayed
• Laxatives and diuretics have very little effect as they occur so long after the binge
• The patient’s self-worth and self-esteem is tied to their body weight and shape
• This is in an excessive and inappropriate way
Complications of Bulimia Nervosa

• Medical consequences:
• Nutritional deficiencies, chronic catabolism (the breakdown of the body), metabolic and
electrolyte disturbances, local tissue damage, surgical complications and neurological
disturbances
• Metabolic and electrolyte imbalances can be lethal
• Hyperkalaemia (over-concentration of potassium) causes cardiac arrhythmias
• Hyponatraemia (low sodium concentration) causes delirium and seizures
• Hypocalcaemia (low calcium) causes cramps, spasms, cardiac problems, panic, confusion
and seizures
• Hypomagnesaemia (low magnesium) nausea, vomiting, lethargy, weakness, personality
change, and tremors
• Excessive diuretics cause dehydration and electrolyte imbalances
• Prolonged laxatives can cause paralytic ileus – bowel paralysis and obstructions
• Excessive vomiting causes erosion of dental enamel, cavities, tooth loss, enlarged salivary
glands, oesophageal ruptures and callouses on the hands
• Ironically people with BN actually have more body fat than is expected for their age group
• Psychological disorders that are common comorbidities: depressive, bipolar, anxiety,
substance and personality disorders
• Up to 80% of patients will have an anxiety disorder at least once
• 50% to 70% of patients will have depression during their BN
• 36.8% will have substance abuse issues

BN Specific Treatment Considerations

• the First stage is psychoeducation on the dangers of binging and purging and how to maintain
healthy eating habits
• Dieting/restrictive eating promotes binges
• This is done through nutritional counselling
• Next focus on negative attitudes regarding body weight, shape and eating
• Coping strategies to resist purging after eating are put in place
• This can mean not being alone after eating in the early treatment stages
• CBT and IPT are used to treat BN
• CBT is faster but both have similar remission rates in the long term
• CBT-E is even better in its results
• People who do not respond to CBT respond well in IPT
• Family therapy is also used in BN
• Focus is on conflicts and dysfunctional attitudes around eating
• CBT-E combined with interpersonal strategies and family therapy is the most effective
treatment
• Medication and short-term CBT have small efficacy rates
• Treatment is long-term and medication is only used to treat co-morbidities
Binge-Eating Disorder (BED)

• This was only formally recognised as a disorder in the DSM-5

• This disorder only started getting attention in the 1990s
• This is different to other eating disorders
• Has different heritability patterns, is mostly in males and a later onset
age
• It has better treatment response rates and better remission rates
• It is associated with severe obesity and is often found in weight
control programmes
• Obesity is a symptom, not the disorder
• About 50% of patients seeking bariatric surgery have BED
• Only about half of patients will attempt weight modification through
dieting
• These patients ted to have more severe BED and are at greater risk
for other comorbidities
• There are similar concerns with shape and weight as with BN and AN
• This distinguishes them from people who are just obese without BED
• 33% of patients binge to avoid bad mood or affect
• These people have more psychological distress
BED Specific Treatment Considerations

• Stopping the binging is vital in reducing obesity and maintaining weight loss
• CBT and IPT are as effective as treatment options
• Medication has no added benefit when combined with therapy
• Some behavioural weight loss programmes have some positive effect on binging
• E.g. Weight Watchers teaches healthy eating habits and positive physical activity
• These programmes act similarly to nutritional counselling and psychoeducation
• Racial groups tend to have different treatment needs
• African-Americans have higher BMIs and Hispanics tend to have greater concerns about
body shape
• Self-help programmes are effective in treating BED
• This is a good first step to avoid expensive professional-led treatments
• Weight loss itself is not sufficient
• Treatment needs to target the underlying maladaptive behaviour that leads to binging

Management of Eating Disorders

• There is a need to evaluate and stabilise a patient physically first

• Hospital admission, close work with a doctor, involving dieticians and other health
professionals
• Focus first on rehydration, electrolyte balancing, stabilising bodily functions and re-feeding
• Sometimes feeding is done through NG tubes
• Pharmacology
• Medication has not been proven effective for AN
• SSRIs are helpful in reducing the cycle of BN
• Medication is only helpful in treating co-morbid disorders and can assist therapy’s efficacy
• Psychology
• Treatment of choice targets problem eating behaviours, distorted body evaluation,
maladaptive weight control and attitudes about body shape and weight
• This style of treatment is applicable to all eating disorders
• Most treatments have a CBT focus with integrations of family therapy and self-image work
(Called CBT-E – enhanced CBT)
• Treatments also focus on self-esteem, individual identities and family therapies
 • There is a strong family influence of perfectionism that is targeted

Causes of Eating Disorders

• There is not just one cause

• There is an interaction with many influences or causes
• Although very different, eating disorders share their causes
• Inherited vulnerabilities – excessive responsiveness to stress, mood intolerance and inherited
traits associated with depression and anxiety
• Sociocultural influences – the thin ideal, diet culture and peer influences
• Strong family influences – high-achieving, competitive, perfectionistic families
• Personality development – certain personality traits are associated with each disorder
• Control, restraint ad obsessive-compulsive behaviour result in AN
• Emotional responsivity and impulsivity result in BN
• Shared psychological attributes: anxiety about body appearance, distorted body image and
maladaptive eating behaviours
• Think about the causal factors discussed for these

Preventing Eating Disorders

• Many patients are treatment-resistant and will have physical complications for many years
• Thus prevention is vital
• Targeting girls aged 15+ and focusing on eliminating hyper-focus on body weight and instead
accepting one’s body is promising
• Focus on improved body image and reducing the drive for thinness
• Selected interventions are better than universal interventions
• Target at-risk populations – adolescent girls
• College girls in sororities are at higher risk than girls not in sororities – there is some social
pressure at play here
• Modern prevention programmes are being developed for online access
• The Body Project

Epidemiology of Eating Disorders

• 90% to 95% of patients with BN are female

• Males with BN have an alter age of onset and a significant portion is gay or bisexual
• Males who are athletes in sports that require weight regulation are the other proportion
• The incidence of males is rising and historically the vast majority of cases recorded were
males
• Young women and adolescents are most at risk for eating disorders
• 12% of adolescent girls will have some kind of eating disorder by the age of 20
• 29%-34% will restrict food, 14%-18% will engage in binging, 14%-17% will have binging and
purging and 6%-7% have bulimic-like behaviour
• Average age of onset for all eating disorders is 18 to 21 years
• Often the age is 10 too, especially in BN With AN the age of onset can be younger than this
• Once bulimia develops, it is chronic if untreated and has a poor prognosis
• Only a third of patients will achieve full remission
• A third fully relapse
• The strongest predictor for persistence is childhood obesity and emphasis on thinness
• Patients also keep their BN symptoms rather than shift to other eating disorders
• AN is also chronic but not as severe as BN if treatment is swift
• Patients keep a low BMI and still have distorted body images thus they continue to restrict
eating
• AN is thought of as more resistant to treatment
• If AN is identified early and treatment is specified response rates are better
 • Immigrants who recently settle in Westernised countries are at higher risk for developing
eating disorders
• White adolescent girls have a higher risk for eating disorders than their counter parts from
other races
• However, there is an increase in non-white racial groups in recent years
• After puberty, girls tend to gain weight, specifically fat tissue
• Boy develop muscle and lean tissue
• This takes girls further way from the western ideal for beauty standards
• Negative attitudes towards weight emerge as early as three years
• More than half of girls between 6 and 8 years would like to be thinner
• By 9 years, 20% of girls try to lose weight
• By 14 years, 40% of girls try to lose weight
• BN and AN can occur in later year, especially after 55 years
• This is a little understood phenomenon

Theme 3: Sleep-Wake Disorders

Listed Sleep-Wake Disorders

• Insomnia Disorder
Condition in which insufficient sleep interferes with normal functioning
• Dyssomnias
Problems in getting to sleep or in obtaining sufficient quality sleep
• Narcolepsy
Sleep disorder involving sudden and irresistible sleep attacks
• Breathing-related sleeping disorders
Sleep disruption leading to excessive sleepiness or insomnia caused by a breathing problem
• Sleep apnoea – disorder involving brief periods when breathing ceases during sleep
• Hypoventilation – decreased ventilation or movement of air in and out of the lungs
• Circadian rhythm sleep disorder
Sleep disturbances resulting in sleepiness or insomnia are caused by the body’s inability to
synchronise its sleep patterns with the current pattern of day and night
• Parasomnias
Abnormal behaviours such as nightmares or sleepwalking that occurred during sleep
• Hypersomnolence disorder
Sleeping disturbance characterised by excessive amount of sleep that disrupts normal
routines
• Nocturnal eating syndrome
During sleep, individuals will consume large amounts of food, sometimes uncooked or other
dangerous foods
Insomnia Disorder

• Is one of the most common complaints in

practice
• DIMS acronym
Disorders of Initiation and Maintenance of
Sleep
Can’t fall asleep, stay asleep or have good
quality sleep
• Non-restorative sleep is when people wake
up unrested despite sleeping for long periods
of time
• Consequences involve a disruption of
psychosocial functioning
• The effects are only felt when awake
• Even if they can go about their day, patients
experience a drop in productivity, and
problem-solving skills and can be dangerous
when doing activities (like driving)
• Primary insomnia – difficulty initiating or
maintaining sleep, or experiencing sleep as
not restorative, not related to other medical
or psychological problems
• Secondary insomnia – difficulty initiating or
maintaining sleep, or experiencing sleep as
not restorative, caused by an identifiable
medical or psychological condition
• Emotional difficulties due to insomnia:
depression, irritability, testiness, excessive
emotionality, a tendency to catastrophise,
procrastination, sleep anxiety and a lack of
self-confidence
• Children with insomnia: poorer adjustment to school, increased hyperactivity, more emotional
and bursts, and poorer a classroom self-regulation and pro social skills
• South African prevalence is at 10% of the population for primary insomnia
• Women report insomnia twice as much as men
• Women report more problems in initiating sleep
• The Mediterranean Diet is shown to be a protective factor – high intake of fruit and veggies,
legumes, unsaturated fatty acids found in olive oil, and lower intake of caffeine/alcohol
• Complaints of insomnia over differing ages alters frequency rates
• Insomnia in children ranges between 20% to 40%
• Children with insomnia throw tantrums and cry when they wake up in the middle of the night
• With adolescence, bedtime shifts to later times
• Complaints of poor sleep increases with age up to late middle age
• In the elderly insomnia complaints drop off – however duration of sleep needed decreases
substantially

Causes of Insomnia Disorder

• Six factors play a role in insomnia

1. Biological vulnerability – natural arousal rates, circadian rhythm issues, and thermoregulation
2. Maladaptive sleep habits – noise, light, uncomfortable bedding, excessive temperatures,
daytime naps, stimulation late in the day, drinking caffeine before bed, large late meals and
substances (alcohol and nicotine)
3. Sleep expectations – having too high expectations of the duration and quality of sleep.
Not everyone needs 8 hours, but preoccupation with this causes disruptions
4. Anxiety about sleep – there is much frustration and anxiety around falling asleep which in turn
exacerbates anxiety that stops sleep
5. Attitudes of parents – excessive positive attention during the night promotes waking, and
dependence on parental presence to fall asleep causes distress when waking
6. Persistence of stressors – occupational, relational and personal stressors that cause
emotional distress
• Like having an argument with your partner right before bedtime