11.9 Eating Disorders, Sleep Disorders & Sexual Health

ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)

11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

11.9 Eating Disorders, Sleep Disorders & Sexual Health

Key Takeaways Explain This Topic AI

Eating disorders excluding obesity, sleep disorders listing insomnia and narcolepsy, and sexual disorders with gender dysphoria are three separate blueprint subsections.

Anorexia nervosa has the highest mortality of the eating disorders, from cardiac complications and suicide.

Refeeding syndrome causes hypophosphatemia, hypokalemia and hypomagnesemia within days of nutritional repletion and can be fatal.

Cognitive behavioral therapy for insomnia is first-line and superior to hypnotic medication for chronic insomnia.

Narcolepsy type 1 features cataplexy with low cerebrospinal fluid hypocretin and is diagnosed by polysomnography followed by a multiple sleep latency test.

Last updated: August 2026

1. Anorexia Nervosa

Restriction of energy intake leading to significantly low body weight, with intense fear of weight gain and disturbance in the experience of body weight or shape. Two subtypes: restricting and binge-eating/purging .

Anorexia nervosa has the highest mortality rate of any psychiatric disorder except opioid use disorder , from cardiac complications and from suicide.

Medical complications by system

• System Findings
• Cardiac Bradycardia, hypotension , QT prolongation, reduced myocardial mass, mitral valve prolapse, arrhythmia

Endocrine Functional hypothalamic amenorrhea , low luteinizing and follicle-stimulating hormone, low estradiol, euthyroid sick syndrome , hypercortisolemia

• Bone Osteopenia and osteoporosis with fracture risk; often irreversible
• Hematologic Pancytopenia from gelatinous marrow transformation
• Gastrointestinal Delayed gastric emptying, constipation, elevated aminotransferases
• Metabolic Hypoglycemia, hypercholesterolemia
• Renal Reduced glomerular filtration rate, nephrolithiasis

Bradycardia in a young woman with low body weight is a warning sign, not athletic conditioning. Severe bradycardia, hypotension, orthostasis, hypothermia, electrolyte disturbance, arrhythmia and very low weight are indications for inpatient medical stabilization .

Osteoporosis in anorexia nervosa is not treated primarily with bisphosphonates. The effective intervention is weight restoration and resumption of menses . Oral contraceptives do not improve bone density in this population and can mask the return of spontaneous menstruation, which is an important marker of recovery.

Refeeding syndrome

The acute hazard of treatment. As carbohydrate is reintroduced, insulin drives phosphate, potassium and magnesium intracellularly in a patient whose total body stores are already depleted.

Hypophosphatemia is the hallmark , and can cause rhabdomyolysis, hemolysis, respiratory muscle failure, arrhythmia, seizures and death

• Also hypokalemia, hypomagnesemia, thiamine deficiency and fluid overload
• Typically occurs within the first several days of refeeding

Prevention: start at a conservative caloric level and advance gradually, give thiamine before feeding , and monitor and replete phosphate, potassium and magnesium daily during the initial period. The exam answer to how do you avoid killing this patient is nearly always start low, go slow, replete electrolytes and give thiamine .

2. Bulimia Nervosa and Binge-Eating Disorder

Bulimia nervosa: recurrent binge eating with compensatory behaviors — vomiting, laxatives, diuretics, fasting, excessive exercise — with weight typically normal or above normal , which is why it is missed.

Physical clues: parotid enlargement , dental enamel erosion on the lingual surfaces, Russell sign (calluses on the dorsum of the hand from self-induced vomiting), and menstrual irregularity.

Laboratory signature of purging: hypokalemic, hypochloremic metabolic alkalosis from vomiting, and a low urine chloride . Laxative abuse instead produces a non-anion-gap metabolic acidosis with hypokalemia.

Treatment: cognitive behavioral therapy is first-line; fluoxetine is the only antidepressant approved for bulimia and is used at higher doses than for depression. Bupropion is contraindicated in eating disorders with purging because of an increased seizure risk.

Binge-eating disorder involves binges without compensatory behavior, and is the most common eating disorder. Treatment is cognitive behavioral therapy, with lisdexamfetamine and some antidepressants as options.

Screening question worth knowing: the SCOFF questionnaire is a brief validated screen usable in primary care.

3. Insomnia

Chronic insomnia is difficulty initiating or maintaining sleep with daytime consequences, occurring at least three nights weekly for at least three months.

Evaluate for secondary causes first: obstructive sleep apnea, restless legs syndrome, depression and anxiety, chronic pain, nocturia, gastroesophageal reflux, and medications and substances — caffeine, alcohol (which fragments sleep despite hastening onset), stimulants, corticosteroids, beta-blockers, decongestants.

Cognitive behavioral therapy for insomnia (CBT-I) is first-line and is superior to hypnotics for durable benefit. Its components:

• Stimulus control — bed only for sleep and sex; leave the bed if awake beyond about 20 minutes
• Sleep restriction — compress time in bed to actual sleep time, then extend as efficiency improves
• Sleep hygiene — consistent wake time, dark cool room, no screens, no clock-watching
• Cognitive restructuring of catastrophic beliefs about sleep
• Relaxation training

Pharmacotherapy is adjunctive and short-term. Benzodiazepines and Z-drugs (zolpidem, eszopiclone) cause tolerance, dependence, next-day impairment, complex sleep behaviors and falls and fractures in older adults — both classes appear on the Beers Criteria . Diphenhydramine and other anticholinergic sleep aids should be avoided in older adults. Melatonin receptor agonists and orexin receptor antagonists are alternatives.

4. Narcolepsy and Other Sleep Disorders

Narcolepsy results from loss of hypothalamic hypocretin (orexin) neurons.

The tetrad:

Excessive daytime sleepiness — universal; irresistible sleep attacks

Cataplexy — sudden bilateral loss of muscle tone triggered by emotion , especially laughter, with preserved consciousness . Pathognomonic when present, and defines type 1

• Sleep paralysis
• Hypnagogic or hypnopompic hallucinations

Diagnosis: overnight polysomnography (to exclude sleep apnea and confirm adequate sleep) followed by a multiple sleep latency test showing short mean sleep latency and two or more sleep-onset REM periods. Low cerebrospinal fluid hypocretin confirms type 1.

Treatment: scheduled naps and sleep hygiene, wake-promoting agents (modafinil, armodafinil, solriamfetol, pitolisant), stimulants, and sodium oxybate for cataplexy and disrupted nocturnal sleep. Cataplexy also responds to serotonergic and noradrenergic antidepressants , and abrupt withdrawal of these can cause status cataplecticus.

Other parasomnias worth recognizing:

REM sleep behavior disorder — dream enactment with loss of normal REM atonia. A strong predictor of future alpha-synucleinopathy (Parkinson disease, Lewy body dementia, multiple system atrophy). Treated with melatonin or clonazepam and by making the sleep environment safe.

Restless legs syndrome — urge to move with unpleasant sensations, worse at rest and in the evening, relieved by movement. Check ferritin and supplement iron if it is low ; also associated with pregnancy, kidney disease and dopamine antagonists. Alpha-2-delta ligands are now preferred over dopamine agonists because of augmentation .

5. Sexual Disorders and Gender Dysphoria

A named blueprint subsection. The internist role is recognizing medical and pharmacologic contributors, providing non-judgmental care, and knowing the basic principles of gender-affirming care.

Sexual dysfunction

Common medical and pharmacologic contributors:

• Category Examples
• Endocrine Diabetes, hypogonadism, hyperprolactinemia, thyroid disease
• Vascular Atherosclerosis, hypertension
• Neurologic Multiple sclerosis, spinal cord injury, neuropathy
• Psychiatric Depression, anxiety, prior trauma, relationship distress
• Medications SSRIs , beta-blockers, thiazides, finasteride, antiandrogens, antipsychotics, opioids

Antidepressant-associated sexual dysfunction is common, is a leading cause of non-adherence, and is frequently not volunteered. Strategies include dose reduction, switching to bupropion or mirtazapine, or adding bupropion.

In women , evaluate for genitourinary syndrome of menopause , which causes dyspareunia from vulvovaginal atrophy and responds well to low-dose vaginal estrogen — a treatment with minimal systemic absorption that is appropriate even for many women in whom systemic hormone therapy is not.

In men , see the discussion of erectile dysfunction; the key safety point is that phosphodiesterase-5 inhibitors are absolutely contraindicated with nitrates .

Gender dysphoria and gender-affirming care

Gender dysphoria is clinically significant distress associated with incongruence between experienced gender and sex assigned at birth. Being transgender is not itself a mental disorder ; the diagnosis describes distress, and many transgender people do not have it.

Principles of respectful care , which are themselves testable:

• Use the patient's stated name and pronouns consistently across the record and the team
• Take an organ inventory rather than assuming anatomy from gender identity

Screen based on the organs present , not on gender marker: a transgender man who retains a cervix needs cervical cancer screening; a transgender woman who retains a prostate is subject to prostate-related considerations

Ask about hormone therapy and surgical history when clinically relevant , not out of curiosity

Medical aspects of hormone therapy the internist should know:

Feminizing therapy (estrogen with an antiandrogen such as spironolactone): monitor for venous thromboembolism — risk is highest with ethinyl estradiol and with smoking — hypertriglyceridemia, hyperkalemia from spironolactone, and prolactin elevation.

Masculinizing therapy (testosterone): monitor hematocrit for erythrocytosis , lipids, blood pressure, and hepatic enzymes. Testosterone is not a contraceptive , and pregnancy remains possible in a patient with a uterus and ovaries.

Laboratory reference ranges should be interpreted according to the hormonal milieu and organ inventory; creatinine and hemoglobin ranges in particular shift with sustained hormone therapy.

Health disparities in transgender populations — higher rates of depression, suicidality, HIV, substance use, and avoidance of care because of prior discriminatory experiences — are recognized targets of the health equity content that ABIM has stated will appear in its assessments.