Comer, Abnormal Psychology, 7th edition
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Transcript Comer, Abnormal Psychology, 7th edition
Eating Disorders
Chapter 11
Slides & Handouts by Karen Clay Rhines, Ph.D.
Northampton Community College
Comer, Abnormal Psychology, 7e
Eating Disorders
Although not historically true, current
Western beauty standards equate thinness
with health and beauty
There has been a rise in eating disorders in
the past three decades
Thinness has become a national obsession
The core issue is a morbid fear of weight gain
Two main diagnoses:
Anorexia nervosa
Bulimia nervosa
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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
Disturbed body perception
Amenorrhea
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Anorexia Nervosa
There are two main subtypes:
Restricting type
Lose weight by cutting out sweets and fattening
snacks, eventually restricting nearly all food
Show almost no variability in diet
Binge-eating/purging type
Lose weight by vomiting after meals, abusing laxatives
or diuretics, or engaging in excessive exercise
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 2% of females in
Western countries develop the disorder
Many more display some symptoms
Rates of anorexia nervosa are increasing in
North America, Japan, and Europe
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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 or life transition
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
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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 shape and weight
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Anorexia Nervosa:
The Clinical Picture
Despite their dietary restrictions, people
with anorexia nervosa are extremely
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
Adjustable lens assessment 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 may also
display certain psychological problems:
Depression (usually mild)
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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The Vicious Cycle of Anorexia
Fear of obesity and distorted body image lead to…
Starvation
Preoccupation with food
Harder attempts at thinness
Increased anxiety & depression
Greater feelings of fear & loss of control
Medical problems
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Bulimia Nervosa
Bulimia nervosa, also known as
“binge-purge syndrome,” is
characterized by binges:
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,
which mark the subtype of the condition:
Purging-type bulimia nervosa
Vomiting
Misusing laxatives, diuretics, or enemas
Nonpurging-type bulimia nervosa
Fasting
Exercising frantically
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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
“Binge-eating disorder” may be a related
diagnosis
Symptoms include a pattern of binge eating with
NO compensatory behaviors (such as vomiting)
This pattern is not yet listed in the DSM-IV-TR
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Bulimia Nervosa
Teens and young adults have
frequently attempted binge-purge
patterns as a means of weight loss,
often after hearing accounts of bulimia
nervosa from friends or the media
According to global studies, 50% of
students report periodic binge-eating
or self-induced vomiting
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Bulimia Nervosa: Binges
For people with bulimia nervosa, the
number of binges per week can range from
1 to 30
Binges are often carried out in secret
Binges involve eating massive amounts of food
rapidly with little chewing
Usually sweet foods with soft texture
Binge-eaters commonly consume more than
1000 calories (often more than 3000 calories)
per binge episode
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Bulimia Nervosa: Binges
Binges are usually preceded by
feelings of great tension and/or
powerlessness
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 “discovery”
Comer, Abnormal Psychology, 7e
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Bulimia Nervosa:
Compensatory Behaviors
After a binge, people with bulimia nervosa
try to compensate for and “undo” the caloric
effects
The most common compensatory behaviors:
Vomiting
Fails to prevent the absorption of half the calories
consumed during a binge
Affects ability to feel satiated greater hunger and
bingeing
Laxatives and diuretics
Also almost completely fail to reduce the number of
calories consumed
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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 subjects, bingeing often occurs
after strict dieting
For example, a study of binge-eating behavior
in a low-calorie weight loss program found
that 62% of patients reported binge-eating
episodes during treatment
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Bulimia Nervosa vs.
Anorexia Nervosa
Similarities:
Onset after a period of dieting
Fear of becoming obese
Drive to become thin
Preoccupation with food, weight, appearance
Feelings of anxiety, depression, obsessiveness,
perfectionism
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
worried 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:
People with bulimia nervosa tend to be controlled
by emotion – may change friendships easily
People with bulimia nervosa are more likely to
display characteristics of a 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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What Causes Eating
Disorders?
Most theorists subscribe to a
multidimensional risk perspective:
Several key factors place individuals at risk
More factors = greater risk
Leading factors:
Psychological problems (ego, cognitive, and mood
disturbances)
Biological factors
Sociocultural conditions (societal and family pressures)
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What Causes Eating Disorders?
Psychodynamic Factors: Ego Deficiencies
Hilde Bruch developed a largely
psychodynamic theory of eating
disorders
Bruch argues that eating disorders
are the result of disturbed mother–
child interactions, which lead to
serious ego deficiencies in the child
and to severe cognitive 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
internal needs; they feed when the child is
anxious, comfort when the child is tired, etc.
There is some empirical support for Bruch’s
theory from clinical reports
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What Causes Eating Disorders?
Cognitive Factors
Bruch’s theory also contains several
cognitive factors
According to cognitive theorists, such
deficiencies contribute to a broad
cognitive distortion that is at the center of
disordered eating (e.g., disproportionate
concerns about body shape and weight)
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What Causes Eating Disorders?
Mood Disorders
Many people with eating disorders,
particularly those with bulimia
nervosa, experience symptoms of
depression
Theorists believe mood disorders may
“set the stage” for eating disorders
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What Causes Eating Disorders?
Mood Disorders
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 mood 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 model:
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 LH and
VMH 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
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 food,
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
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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
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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 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
For other men, body image appears to
be a key factor
A new kind of eating disorder has
emerged and is found almost exclusively
among men – reverse anorexia nervosa or
muscle dysmorphobia
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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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How Are Eating Disorders
Treated?
Eating disorder treatments have two
main goals:
Correct abnormal 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 initial 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 an
outpatient setting
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 applied
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”
Such approaches can take place in either
individual or group therapy formats
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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
Another focus of treatment is correcting
disturbed cognitions, especially client
misperceptions and 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
Another focus of treatment is
changing family interactions
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
83% of patients still showed
improvements after several years
Menstruation often returns with return to
normal weight
The death rate from anorexia nervosa is
declining
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Treatments for
Anorexia Nervosa
Negatives of treatment:
Close to 20% 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
specialized 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
Cognitive-behavioral therapy is particularly
helpful:
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
Cognitive-behavioral therapy is particularly
helpful:
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 therapy provides 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,
especially when combined with individual insight therapy
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Treatments for
Bulimia Nervosa
Antidepressant medications
During the past decade, 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 90% 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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