Curbing Nocturnal Binges in Sleep-Related Eating Disorder

pSYCHIATRY Curbing nocturnal binges in sleep-related eating disorder Sleepwalking-like behavior is a frequently undiagnosed cause of patients’ obesity s. G, age 39, has a body mass index® Dowden(BMI) >35 Health Media kg/m2 and is pursuing bariatric surgery to treat Mobesity. She is frustrated with dieting and describes a decade of Copyrightunconscious Fornocturnal personal eating, use only including peanut butter and uncooked spaghetti. This behavior began after her divorce 10 years ago. Initially she had partial recall of the nocturnal binges, but now describes full amnesia. Treatment for a depressive episode did not control her nocturnal eating. Sleep-related eating disorder (SRED) can be associated with disrupted sleep, weight gain, and major chronic morbidity. In SRED—involuntary eating while asleep, BENNETT with partial or complete amnesia—the normal suppres- PETER sion of eating during the sleep period is disinhibited. 2007 © The disorder can be idiopathic, associated with medication use, or linked to other sleep disorders such as Michael J. Howell, MD Minnesota Regional Sleep Disorders Center somnambulism (sleepwalking), restless legs syndrome Hennepin County Medical Center (RLS), periodic limb movement disorder (PLMD), or Assistant professor, department of neurology obstructive sleep apnea (OSA). Carlos Schenck, MD SRED is more common in women than men; it Minnesota Regional Sleep Disorders Center usually begins in the third decade of life but can be- Hennepin County Medical Center Associate professor, department of psychiatry gin in childhood or middle age. About one-half of Scott J. Crow, MD SRED patients also have a psychiatric illness, usu- Director, Clinical Populations/Assessment Core ally a mood disorder. Unremitting SRED may lead to Minnesota Obesity Center psychopathology, as the onset of sleep-related eating Professor, department of psychiatry usually precedes the onset of a psychiatric disorder by years. University of Minnesota, Minneapolis SRED often is unrecognized, but it can be effec- tively identified and treated. This article examines Current Psychiatry how to: Vol. 6, No. 7 19 For mass reproduction, content licensing and permissions contact Dowden Health Media. Box To meet diagnostic criteria for SRED, Sleeping and eating: patients must experience involuntary nocturnal eating and demonstrate at least 1 Closely linked activities other symptom, such as: ecause hormones that regulate • eating peculiar, inedible, or toxic sub- B appetite, food intake, and body stances weight also play a role in sleep regulation, • engaging in dangerous behavior while Sleep-related patients with eating disorders often preparing food (Table 1). eating have associated sleep disorders. For example, obesity is related to obstructive Level of consciousness. In both SRED and sleep apnea (OSA)—weight gain is a risk NES, patients demonstrate morning an- factor for OSA, and weight loss often orexia. However, patients with NES report is an effective treatment.1 Moreover, being awake and alert during their noctur- patients with anorexia nervosa frequently nal eating, whereas patients with SRED de- demonstrate sleep initiation and scribe partial or complete amnesia. SRED maintenance insomnia.2 patients with partial awareness often Clinical Point Conversely, epidemiologic studies have demonstrated that sleep duration is describe the experience as being involun- SRED patients with inversely correlated with body mass index. tary, dream-like, and “out-of-control.” In- partial awareness In particular, individuals with shorter sleep terestingly, hunger is notably absent dur- times are more likely to be overweight.3 ing most episodes in which patients have often describe the The nature of this association is unclear; at least partial awareness. experience as being however, hormones that normally regulate Typically, patients cannot be awakened involuntary, dream- appetite are disrupted in patients with easily from a sleep-eating episode. In this sleep deprivation. For instance, leptin is regard, SRED resembles sleepwalking. like, and ‘out-of- an appetite suppressant that is normally Sleepwalking without eating often pre- released from adipocytes during sleep, so control’ cedes SRED, but once eating develops it of- sleep deprivation may promote hunger by ten becomes the predominant or exclusive restricting its secretion.4 sleepwalking behavior. This pattern has led many researchers to consider SRED a • distinguish SRED from nocturnal eating “sleepwalking variant disorder.” syndrome (NES) and other disorders • identify precipitating causes Eating episodes in SRED are often charac- • select effective pharmacologic therapy. terized by binge eating, and many patients describe at least one episode per night.5 They usually eat high-calorie foods. The Diﬀ erentiating SRED from NES spectrum of cuisine is broad, ranging from Eating and sleeping—and disorders of dry cereal to hot meals that require more each—are closely linked (Box).1-4 SRED than 30 minutes to prepare. Patients treat- and night eating syndrome (NES) are 2 ed at our sleep center report eating foods principal night eating disorders. SRED is that are high in simple carbohydrates, characterized by inappropriately consum- fats, and—to a lesser extent—protein. Pea- ing food after falling asleep,5 whereas NES nut butter—a preferred item—can lead to is characterized by hyperphagia after the near-choking episodes when patients fall evening meal, either before bedtime or af- asleep with peanut butter in their mouths ter fully awakening during the night.6 and wake up gasping for air. Alcohol consumption is rare. SRED episodes can be hazardous, with Want to know more? risks of drinking or eating excessively hot Download this related article. liquids or solids, choking on thick foods, or Visit CurrentPsychiatry.com receiving lacerations while using knives to Beating obesity: Help patients control prepare food. Patients may consume foods binge eating disorder and night to which they are allergic or eat inedible or Current Psychiatry eating syndrome • June 2006 20 July 2007 even toxic substances (Table 2, page 22).5,7-9 Table 1 Diagnostic criteria for sleep-related eating disorder IMPACTFUL A. Recurrent episodes of involuntary eating and drinking during the main sleep period B. One or more of the following must be present with FACTS these recurrent episodes: 1. Consumption of peculiar, inedible, or toxic substances 2. Insomnia related to repeated episodes of eating, with a complaint of nonrestorative sleep, daytime fatigue, or somnolence 3. Sleep-related injury 4. Dangerous behavior while preparing food Adults with ADHD 5. Morning anorexia 6. Adverse health consequences from recurrent binge eating were 2x more C. The disturbance is not better explained by another sleep, medical, or neuropsychiatric disorder likely to have been Source: International classiﬁ cation of sleep disorders: diagnostic and coding manual, 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005:174-5. involved in 3 or 1 Chain of consequences more car crashes* Repeated nocturnal binge eating episodes can have multiple adverse health effects.5,7 Patients often wake up with painful abdominal distention. Weight gain and subsequent increased BMI may compromise the control of medical complications such as diabetes mellitus, hyperlipidemia, hypertri- The consequences may be serious. glyceridemia, hypertension, OSA, and cardiovas- Screen for ADHD. cular disease. Patients with SRED also report den- tal problems such as tooth chipping and increased incidence of caries. Find out more at Failure to control nocturnal eating can lead to www.consequencesofadhd.com secondary depressive disorders related to excessive weight gain. Moreover, SRED patients’ nighttime and download patient support materials, behaviors may disrupt their bed partners’ sleep coupons, and adult screening tools. and cause interpersonal and marital problems. Untreated SRED is usually unremitting. In our experience, most patients describe suffering for years before seeking treatment. Many report that *Data from a study comparing driving in 105 young adults with their symptoms have been dismissed by other phy- ADHD to 64 community control adults without the disorder. Reference: 1. Barkley RA, Murphy KR, DuPaul GJ, Bush T. Driving in young sicians or wrongly attributed to a mood disorder. adults with attention deficit hyperactivity disorder: knowledge, performance, Not surprisingly, patients in obesity clinics and eat- adverse outcomes, and the role of executive functioning. J Int Neuropsychol Soc. 2002;8:655-672. ing disorder groups regularly report SRED. Multiple causes Shire US Inc. Medication-induced. The commonly prescribed ... your ADHD Support Company™ 10,11 hypnotic zolpidem can induce SRED. Sporad- ©2006 Shire US Inc., Wayne, Pennsylvania 19087 A1409 10/06 ic cases of SRED have been reported with other psychotropics, such as tricyclic antidepressants, Table 2 sleep and nocturnal eating behavior 2 weeks Typical foods consumed before a clinic visit. These diaries help docu- while sleep-eating ment sleep and eating patterns and assess the patient’s awareness and subsequent recall. Simple Peanut butter, dry cereal, As described above, recurrent nighttime candy, bread/toast eating with full awareness and control Peculiar Uncooked spaghetti, sugar/ would be best characterized as NES. How- Sleep-related salt sandwiches, cat/dog ever, there is some debate as to the extent eating food, frozen food that SRED can manifest with substantial 13 Inedible/toxic

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