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Eating Disorders
Chapter 11
Comer, Abnormal Psychology, 8eDSM-5 Update
Slides & Handouts by Karen Clay Rhines, Ph.D.American Public University System
2Comer, Abnormal Psychology, 8e
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Eating Disorders
It has not always done so, but Western society today equates thinness with health and beauty Thinness has become a national obsession
There has been a rise in eating disorders in the past three decades The core issue is a morbid fear of weight gain
Two main diagnoses: Anorexia nervosa Bulimia nervosa
Eating Disorders
A third disorder – binge eating disorder – also appears to be on the rise Fear of weight gain is not to the same
degree as with anorexia or bulimia
People with this disorder display many of the other features found in those disorders
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Anorexia Nervosa
The main symptoms of anorexia nervosa are: A refusal to maintain more than 85% of
normal body weight
Intense fears of becoming overweight
Distorted view of weight and shape
Amenorrhea
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Anorexia Nervosa
There are two main subtypes: Restricting type
Lose weight by cutting out sweets and fattening snacks, eventually eliminating nearly all food
Show almost no variability in diet
Binge-eating/purging type Lose weight by forcing themselves to vomit after
meals or by abusing laxatives or diuretics
Like those with bulimia nervosa, people with this subtype may engage in eating binges
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Anorexia Nervosa
About 90%–95% of cases occur in females
The peak age of onset is between 14 and 18 years
Between 0.5% and 3.5% of females in Western countries develop the disorder Many more display at least some symptoms
Rates of anorexia nervosa are increasing in North America, Europe, and Japan
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Anorexia Nervosa
The “typical” case: A normal to slightly overweight female has
been on a diet Escalation toward anorexia nervosa may
follow a stressful event Separation of parents Move away from home Experience of personal failure
Most patients recover However, about 2% to 6% become seriously ill and
die as a result of medical complications or suicide
Anorexia Nervosa: The Clinical Picture
The key goal for people with anorexia nervosa is becoming thin The driving motivation is fear:
Of becoming obese
Of giving in to the desire to eat
Of losing control of body size and shape
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Anorexia Nervosa: The Clinical Picture
Despite their dietary restrictions, people with anorexia nervosa are preoccupied with food This includes thinking and reading
about food and planning for meals This relationship is not necessarily
causal It may be the result of food deprivation, as
evidenced by the famous 1940s “starvation study” with conscientious objectors
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Anorexia Nervosa: The Clinical Picture
Persons with anorexia nervosa also think in distorted ways: Usually have a low opinion of their body shape Tend to overestimate their actual proportions
Assessed using an adjustable lens technique
Hold maladaptive attitudes and misperceptions “I must be perfect in every way” “I will be a better person if I deprive myself” “I can avoid guilt by not eating”
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Anorexia Nervosa: The Clinical Picture
People with anorexia nervosa also display certain psychological problems: Depression Anxiety Low self-esteem Insomnia or other sleep disturbances Substance abuse Obsessive-compulsive patterns Perfectionism
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Anorexia Nervosa: Medical Problems
Caused by starvation: Amenorrhea
Low body temperature
Low blood pressure
Body swelling
Reduced bone density
Slow heart rate
Metabolic and electrolyte imbalances
Dry skin, brittle nails
Poor circulation
Lanugo
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Bulimia Nervosa
Bulimia nervosa, also known as “binge-purge syndrome,” is characterized by binges: Repeated bouts of uncontrolled
overeating during a limited period of time
Eat objectively more than most people would/could eat in a similar period
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Bulimia Nervosa
The disorder is also characterized by inappropriate compensatory behaviors, including: Forced vomiting
Misusing laxatives, diuretics, or enemas
Fasting
Exercising excessively
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Bulimia Nervosa
Like anorexia nervosa, about 90%–95% of bulimia nervosa cases occur in females
The peak age of onset is between 15 and 21 years
Symptoms may last for several years with periodic letup
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Bulimia Nervosa
Patients are generally of normal weight Often experience marked weight
fluctuations
Some may also qualify for a diagnosis of anorexia
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Bulimia Nervosa
Many teenagers and young adults go on occasional binges or experiment with vomiting or laxatives after hearing about these behaviors from friends or the media
According to global studies, 25-50% of students report periodic binge-eating or self-induced vomiting Only some of these individuals qualify for a
diagnosis of bulimia nervosa
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Bulimia Nervosa: Binges
People with bulimia nervosa may have between 1 and 30 binge episodes per week
Binges are often carried out in secret Binges involve eating massive amounts of food
very rapidly with little chewing Usually sweet, high-calorie foods with soft texture
Binge-eaters commonly consume between as many as 10,000 calories per binge episode
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Bulimia Nervosa: Binges
Binges are usually preceded by feelings of great tension
Although the binge itself may be pleasurable, it is usually followed by feelings of extreme self-blame, guilt, depression, and fears of weight gain and being discovered
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Bulimia Nervosa: Compensatory Behaviors
After a binge, people with bulimia nervosa try to compensate for and “undo” the caloric effects Many resort to vomiting
Fails to prevent the absorption of half the calories consumed during a binge
Repeated vomiting affects the ability to feel satiated greater hunger and bingeing
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Bulimia Nervosa: Compensatory Behaviors
Compensatory behaviors may temporarily relieve the negative feelings attached to binge eating Over time, however, a cycle develops in
which purging bingeing purging…
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Bulimia Nervosa
The “typical” case: A normal to slightly overweight female
has been on an intense diet
Research suggests that even among normal participants, bingeing often occurs after strict dieting
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Bulimia Nervosa vs. Anorexia Nervosa
Similarities: Begin after a period of dieting Fear of becoming obese Drive to become thin Preoccupation with food, weight, appearance Feelings of anxiety, depression, obsessiveness,
perfectionism Heighted risk of suicide attempts Substance abuse Distorted body perception Disturbed attitudes toward eating
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Bulimia Nervosa vs. Anorexia Nervosa
Differences: People with bulimia nervosa are more
concerned about pleasing others, being attractive to others, and having intimate relationships
People with bulimia nervosa tend to be more sexually experienced and active
People with bulimia nervosa are more likely to have histories of mood swings, low frustration tolerance, and poor coping
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Bulimia Nervosa vs. Anorexia Nervosa
Differences: More than one-third of people with bulimia
display characteristics of a personality disorder, particularly borderline personality disorder
Different medical complications: Only half of women with bulimia nervosa experience
amenorrhea vs. almost all women with anorexia nervosa
People with bulimia nervosa suffer damage caused by purging, especially from vomiting and laxatives
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Binge Eating Disorder
Like those with bulimia, individuals with binge eating disorder engage in repeated eating binges during which they feel no control These individuals do not perform inappropriate
compensatory behaviors
As a result of their binges, two-thirds of people with this disorder become overweight or obese It is important to recognize, however, that most
overweight people do not engage in repeated binges
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Binge Eating Disorder
Between 2 and 7% of the population display binge eating disorder
The binges and many other symptoms that characterize this pattern are similar to those seen in bulimia
On the other hand, those with binge eating disorder are not driven to thinness, the disorder doesn’t start following a diet, and there are not large gender differences in the prevalence of this disorder
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What Causes Eating Disorders?
Most theorists and researchers use a multidimensional risk perspective to explain eating disorders: Several key factors place individuals at
risk More factors = greater likelihood of
developing a disorder Leading factors:
Psychological problems Biological factors Sociocultural conditions
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What Causes Eating Disorders? Psychodynamic Factors: Ego
Deficiencies
Hilde Bruch developed a largely psychodynamic theory of eating disorders
Bruch argued that eating disorders are the result of disturbed mother–child interactions, which lead to serious ego deficiencies in the child and to severe perceptual disturbances
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What Causes Eating Disorders? Psychodynamic Factors: Ego
Deficiencies Bruch argues that parents may respond to
their children either effectively or ineffectively Effective parents accurately attend to a child’s
biological and emotional needs Ineffective parents fail to attend to child’s needs;
they feed when the child is anxious, comfort when the child is tired, etc.
Such children may grow up confused and unaware of their own internal needs and turn, instead, to external guides
Clinical reports and research have provided some empirical support for this theory
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What Causes Eating Disorders?
Cognitive Factors Bruch’s theory also contains several
cognitive factors, like improper labeling of internal sensations and needs According to cognitive theorists, these
deficiencies contribute to a broad cognitive distortion that lies at the center of disordered eating (e.g., negative self-judgment based on body shape and weight)
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What Causes Eating Disorders? Depression
Many people with eating disorders, particularly those with bulimia nervosa, experience symptoms of depression Theorists believe depressive disorders
may “set the stage” for eating disorders
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What Causes Eating Disorders? Depression
There is empirical support for the claim that mood disorders set the stage for eating disorders: Many more people with an eating disorder qualify
for a clinical diagnosis of major depressive disorder than do people in the general population
Close relatives of those with eating disorders seem to have higher rates of depressive disorders
People with eating disorders, especially those with bulimia nervosa, have serotonin abnormalities
Symptoms of eating disorders are helped by antidepressant medications
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What Causes Eating Disorders? Biological
Factors Biological theorists suspect certain genes
may leave some people particularly susceptible to eating disorders Consistent with this idea:
Relatives of people with eating disorders are up to 6 times more likely to develop the disorder themselves
Identical (MZ) twins with anorexia: 70% Fraternal (DZ) twins with anorexia: 20% Identical (MZ) twins with bulimia: 23% Fraternal (DZ) twins with bulimia: 9%
These findings may be related to low serotonin
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What Causes Eating Disorders? Biological
Factors Other theorists believe that eating
disorders may be related to dysfunction of the hypothalamus Researchers have identified two
separate areas that control eating: Lateral hypothalamus (LH)
Ventromedial hypothalamus (VMH)
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What Causes Eating Disorders? Biological
Factors Some theorists believe that the hypothalamus,
related brain areas, and chemicals together are responsible for weight set point – a “weight thermostat” of sorts Set by genetic inheritance and early eating
practices, this mechanism is responsible for keeping an individual at a particular weight level
If weight falls below set point: hunger, metabolic rate binges
If weight rises above set point: hunger, metabolic rate Dieters end up in a battle against themselves to
lose weight
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What Causes Eating Disorders?
Societal Pressures Many theorists believe that current
Western standards of female attractiveness are partly responsible for the emergence of eating disorders Western standards have changed
throughout history toward a thinner ideal Miss America contestants have declined in
weight by 0.28 lbs/yr; winners have declined by 0.37 lbs/yr
Playboy centerfolds have lower average weight, bust, and hip measurements than in the past
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What Causes Eating Disorders?
Societal Pressures Members of certain subcultures are
at greater risk from these pressures: Models, actors, dancers, and certain
athletes Of college athletes surveyed, 9% met full
criteria for an eating disorder while another 50% had symptoms
20% of surveyed gymnasts appear to have an eating disorder
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What Causes Eating Disorders?
Societal Pressures Societal attitudes may explain economic
and racial differences seen in prevalence rates Historically, women of higher SES expressed
more concern about thinness and dieting These women had higher rates of eating disorders
than women of the lower socioeconomic classes
Recently, dieting and preoccupation with thinness, along with rates of eating disorders, are increasing in all groups
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What Causes Eating Disorders?
Societal Pressures The socially accepted prejudice against
overweight people may also add to the “fear” and preoccupation about weight About 50% of elementary and 61% of
middle school girls are currently dieting A recent survey of adolescent girls tied
eating disorders and body dissatisfaction to social networking, Internet activities, and television browsing
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What Causes Eating Disorders?
Family Environment Families may play an important role in
the development of eating disorders As many as half of the families of those
with eating disorders have a long history of emphasizing thinness, appearance, and dieting
Mothers of those with eating disorders are more likely to be dieters and perfectionistic themselves
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What Causes Eating Disorders?
Family Environment Abnormal interactions and forms of
communication within a family may also set the stage for an eating disorder Influential family theorist Salvador
Minuchin cites “enmeshed family patterns” as causal factors of eating disorders
These patterns include overinvolvement in, and overconcern about, family member’s lives
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What Causes Eating Disorders? Multicultural Factors:
Racial and Ethnic Differences
A widely publicized 1995 study found that eating behaviors and attitudes of young African American women were more positive than those of young white American women Specifically, nearly 90% of the white
American respondents were dissatisfied with their weight and body shape, compared to around 70% of the African American teens
The study also suggested that the groups had different ideals of beauty
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What Causes Eating Disorders? Multicultural Factors:
Racial and Ethnic Differences
Unfortunately, research conducted over the past decade suggests that body image concerns, dysfunctional eating patterns, and eating disorders are on the rise among young African American women as well as among women of other minority groups The shift appears to be partly related to
acculturation
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What Causes Eating Disorders? Multicultural Factors:
Racial and Ethnic Differences
Eating disorders among Hispanic American female adolescents are about equal to those of white American women
Eating disorders also appear to be on the increase among Asian American women and young women in several Asian countries
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What Causes Eating Disorders? Multicultural Factors:
Gender Differences
Males account for only 5% to 10% of all cases of eating disorders
The reasons for this striking difference are not entirely clear, but Western society’s double standard for attractiveness is, at the very least, one reason
A second reason may be the different methods of weight loss favored: Men are more likely to exercise Women more often diet
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What Causes Eating Disorders? Multicultural Factors:
Gender Differences
It seems that some men develop eating disorders as linked to the requirements and pressures of a job or sport The highest rates of male eating disorders
have been found among: Jockeys Wrestlers Distance runners Body builders Swimmers
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What Causes Eating Disorders? Multicultural Factors:
Gender Differences
For other men, body image appears to be a key factor
Last, some men seem to be caught up in a new kind of eating disorder – reverse anorexia nervosa or muscle dysmorphobia
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How Are Eating Disorders Treated?
Eating disorder treatments have two main goals: Correct dangerous eating patterns
Address broader psychological and situational factors that have led to, and are maintaining, the eating problem
This often requires the participation of family and friends
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Treatments for Anorexia Nervosa
The immediate aims of treatment for anorexia nervosa are to: Regain lost weight
Recover from malnourishment
Eat normally again
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Treatments for Anorexia Nervosa
In the past, treatment took place in a hospital setting; it is now often offered in day hospitals or outpatient settings
In life-threatening cases, clinicians may need to force tube and intravenous feedings on the patient This may breed distrust in the patient and
create a power struggle In contrast, behavioral weight-restoration
approaches have clinicians use rewards whenever patients eat properly or gain weight
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Treatments for Anorexia Nervosa
The most popular weight-restoration technique has been the combination of supportive nursing care, nutritional counseling, and high-calorie diets Necessary weight gain is often achieved in
8 to 12 weeks Researchers have found that people
with anorexia nervosa must overcome their underlying psychological problems to achieve lasting improvement
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Treatments for Anorexia Nervosa
Therapists use a combination of therapy and education to achieve this broader goal, using a combination of individual, group, and family approaches; psychotropic drugs have been helpful in some cases
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Treatments for Anorexia Nervosa
In most treatment programs, a combination of behavioral and cognitive interventions are included On the behavioral side, clients are
required to monitor feelings, hunger levels, and food intake and the ties among those variables
On the cognitive sides, they are taught to identify their “core pathology”
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Treatments for Anorexia Nervosa
Therapists help patients recognize their need for independence and control
Therapists help patients recognize and trust their internal feelings
A final focus of treatment is helping clients change their attitudes about eating and weight Using cognitive approaches, therapists
correct disturbed cognitions and educate about body distortions
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Treatments for Anorexia Nervosa
Family therapy is important for anorexia nervosa treatment The main issues are often separation
and boundaries
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Treatments for Anorexia Nervosa
The use of combined treatment approaches has greatly improved the outlook for people with anorexia nervosa But even with combined treatment,
recovery is difficult
The course and outcome of the disorder vary from person to person
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Treatments for Anorexia Nervosa
Positives of treatment: Weight gain is often quickly restored
As many as 90% of patients still showed improvements after several years
Menstruation often returns with return to normal weight
The death rate from anorexia nervosa seems to be falling
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Treatments for Anorexia Nervosa
Negatives of treatment: As many as 25% of patients remain troubled
for years Even when it occurs, recovery is not always
permanent Anorexic behavior recurs in at least one-third of
recovered patients, usually triggered by new stresses
Many patients still express concerns about their weight and appearance
Lingering emotional problems are common
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Treatments for Bulimia Nervosa
Treatment is frequently offered in eating disorder clinics
The immediate aims of treatment for bulimia nervosa are to: Eliminate binge-purge patterns Establish good eating habits Eliminate the underlying cause of bulimic
patterns Programs emphasize education as
much as therapy
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Treatments for Bulimia Nervosa
Cognitive-behavioral therapy is particularly helpful: Behavioral techniques
Diaries are often a useful component of treatment
Exposure and response prevention (ERP) is used to break the binge-purge cycle
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Treatments for Bulimia Nervosa
Cognitive-behavioral therapy is particularly helpful: Cognitive techniques
Help clients recognize and change their maladaptive attitudes toward food, eating, weight, and shape
Typically teach individuals to identify and challenge the negative thoughts that precede the urge to binge
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Treatments for Bulimia Nervosa
Other forms of psychotherapy If clients do not respond to cognitive-
behavioral therapy, other approaches may be tried
A common alternative is interpersonal therapy (IPT); a treatment that seeks to improve interpersonal functioning may be tried
Psychodynamic therapy has also been used
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Treatments for Bulimia Nervosa
Other forms of psychotherapy Various forms of psychotherapy are often
supplemented by family therapy and may be offered in either individual or group therapy format
Group formats provide an opportunity for patients to express their thoughts, concerns, and experiences with one another
Group therapy is helpful in as many as 75% of cases
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Treatments for Bulimia Nervosa
Antidepressant medications During the past 15 years, all groups of
antidepressant drugs have been used in bulimia nervosa treatment
Drugs help as many as 40% of patients
Medications are best when used in combination with other forms of therapy
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Treatments for Bulimia Nervosa
Left untreated, bulimia nervosa can last for years
Treatment provides immediate, significant improvement in about 40% of cases An additional 40% show moderate response
Follow-up studies suggest that 10 years after treatment about 75% of patients have fully or partially recovered
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Treatments for Bulimia Nervosa
Relapse can be a significant problem, even among those who respond successfully to treatment Relapses are usually triggered by stress Relapses are more likely among persons
who: Had a longer history of symptoms Vomited frequently Had histories of substance use Have lingering interpersonal problems
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Treatments for Binge Eating Disorder
Given the key role of binges in both bulimia and binge eating disorder, treatments, too, are often similar Cognitive-behavior therapy, other forms of
psychotherapy, and, in some cases, antidepressant medications are provided to reduce or eliminate binge patterns and to change disturbed thinking
People with binge eating disorder who are overweight require additional intervention
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Treatments for Binge Eating Disorder
Now that binge eating disorder has been identified and is receiving considerable study, it is likely that specialized treatment programs will be emerging In the meantime, little is known about
the aftermath of the disorder
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