Bulimia Nervosa

Topic Overview

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Bulimia is one of the most common eating disorders. If you want information on other eating disorders, see the topics Anorexia Nervosa and Binge Eating Disorder.

What is bulimia nervosa?

Bulimia (say 'boo-LEE-mee-uh') is a type of eating disorder. People with bulimia will eat a large amount of food in a short time (binge). Then they will do something to get rid of the food (purge). They may vomit, exercise too much, or use medicines like laxatives.

People who have bulimia may binge because food gives them a feeling of comfort. But eating too much makes them feel out of control. After they binge, they feel ashamed, guilty, and afraid of gaining weight. This causes them to purge.

Without treatment, this 'binge and purge' cycle can lead to serious, long-term health problems. Acid in the mouth from vomiting can cause tooth decay, gum disease, and loss of tooth enamel. Any type of purging can lead to bone thinning (osteoporosis), kidney damage, heart problems, or even death.

If you or someone you know has bulimia or another eating disorder, get help. Eating disorders can be dangerous, and willpower alone is not enough to overcome them. Treatment can help a person with an eating disorder feel better and be healthier.

What causes bulimia?

All eating disorders are complex problems, and experts do not really know what causes them. But they may be caused by a mix of family history, social factors, and personality traits. You may be more likely to have bulimia if:

• Other people in your family are obese, have an eating disorder, or have a mood disorder such as depression or anxiety.
• You have a job or do a sport that stresses body size, such as ballet, modeling, or gymnastics.
• You are the type of person who tries to be perfect all the time, never feels good enough, or worries a lot.
• You are dealing with stressful life events, such as divorce, moving to a new town or school, or losing a loved one.

Bulimia is most common in:

• Teens. Like other eating disorders, bulimia usually starts in the teen years. But it can start even earlier or in adulthood.
• Women. About 10 out of 11 people with bulimia are female. But some boys and men have it too.¹

While bulimia often starts in the teen years, it usually lasts into adulthood and is a long-term disorder.

What are the symptoms?

People with bulimia:

• Binge on a regular basis. They eat large amounts of food in a short period of time, often over a couple of hours or less. During a binge, they feel out of control and feel unable to stop eating.
• Purge to get rid of the food and avoid weight gain. They may make themselves vomit, exercise very hard or for a long time, or misuse laxatives, enemas, water pills (diuretics), or other medicines.
• Base how they feel about themselves on how much they weigh and how they look.

Any one of these can be a sign of an eating disorder that needs treatment.

How can I know if someone has bulimia?

Bulimia is different from anorexia nervosa, another eating disorder. People who have anorexia eat so little that they become extremely thin. People who have bulimia may not be thin. They may be a normal size. They may binge in secret and deny that they are purging. This makes it hard for others to know that a person with bulimia has a serious problem.

If you are concerned about someone, look for the following signs. A person may have bulimia if she:

• Goes to the bathroom right after meals.
• Overeats but does not gain weight.
• Is secretive about eating, hides food, or will not eat around other people.
• Exercises a lot, even when she does not feel well.
• Often talks about dieting, weight, and body shape.
• Uses laxatives or diuretics often.
• Has teeth marks or calluses on the back of her hands or swollen cheeks or jaws. These are caused by making herself vomit.

How is it treated?

Bulimia can be treated with psychological counseling and sometimes medicines, such as antidepressants. The sooner treatment is started, the better. Getting treatment early can make recovery easier and prevent serious health problems.

By working with a counselor, a person with bulimia can learn to feel better about herself. She can learn to eat normally again and stop purging.

Other mental health problems such as depression often happen with bulimia. If a person has another condition along with bulimia, more treatment may be needed, and it may take longer to get better.

Eating disorders can take a long time to overcome, and it is common to fall back into unhealthy ways of eating. If you are having problems, don't try to handle them on your own. Get help.

What should I do if I think someone has bulimia?

It can be very scary to realize that someone you care about has an eating disorder. If you think a friend or loved one has bulimia, you can help.

• Talk to her. Tell her why you are worried.
• Urge her to talk to someone who can help, like a doctor or counselor. Offer to go with her.
• Tell someone who can make a difference-like a parent, teacher, counselor, or doctor. The sooner your friend or loved one gets help, the sooner she will be healthy again.

Frequently Asked Questions

Cause

The cause of bulimia is not clear, but it probably results from a combination of family history, social values (such as admiring thinness), and certain personality traits (such as perfectionism).

Your risk for developing bulimia increases if your parent, sister, or brother has the condition, but this may be only part of the cause.

Stressful life events such as moving, divorce, or the death of a loved one can trigger bulimia in some people.

Many young women, such as those in college or high school, have unhealthy attitudes toward eating and their bodies. Socially, they may accept and encourage destructive behaviors like extreme dieting or binging and purging. These beliefs and behaviors are not normal or healthy. They can play a part in developing eating disorders that need treatment. Women who begin to severely restrict their diets in order to lose weight are at risk for developing bulimia.

Bulimia, like all eating disorders, is a complex physical and psychological condition. Recovery requires treatment that helps you change your behavior and also deals with the deeper attitudes and feelings that cause you to binge and purge.

Symptoms

Symptoms of bulimia include:²

• Repeatedly eating large amounts of food in a short period of time (less than 2 hours).
• Frequently getting rid of the calories you've eaten (purging) by making yourself vomit, fasting, exercising too much, or misusing laxatives, diuretics, ipecac syrup, or enemas. Misuse of these medicines can lead to serious health problems and even death.
• Feeling a loss of control over how much you eat.
• Having binge-purge cycles.
• Feeling ashamed of overeating and very fearful of gaining weight.
• Basing your self-esteem and value upon your body shape and weight.

Any of the above symptoms can be a sign of bulimia or another eating disorder that needs treatment. If you or someone you know has any of these symptoms, talk to a health professional, friend, or family member about your concerns right away.

Bulimia and other eating disorders can be difficult to diagnose, because people often keep unhealthy thoughts and behaviors secret and may deny that they have a problem. Often, a person won't get evaluation and treatment until someone else notices the signs of bulimia and encourages the person to seek the help that he or she needs.

Other signs that a person may have bulimia

Common signs that a person may have bulimia are when the person:^{3, 4}

• Is very secretive about eating and does not eat around other people.
• Sneaks food or hides food in the house. You may notice that large amounts of food are missing.
• Has frequent weight changes. For example, the person may gain and lose large amounts of weight in short periods of time.
• Has irregular menstrual cycles.
• Seems preoccupied with exercise.
• Often talks about dieting, weight, and body shape.
• Seems to be overusing laxatives and diuretics.
• Has low levels of potassium or other blood electrolyte imbalances.
• Looks sick or has symptoms such as:⁵
  • Tooth decay or erosion of tooth enamel.
  • Sore gums or mouth sores.
  • Dry skin.
  • Loose skin.
  • Thin or dull hair.
  • Swollen salivary glands.
  • Bloating or fullness.
  • Lack of energy.
  • Teeth marks on the backs of the hands or calluses on the knuckles from self-induced vomiting.
• Feels depressed, anxious, or guilty.
• Shoplifts food, laxatives, or diuretics.
• Drinks large amounts of alcohol or uses illegal drugs and may have a substance abuse problem.

Conditions that commonly occur with bulimia, such as depression, substance abuse, or anxiety disorders, can make treatment of bulimia more difficult. Recovery from bulimia can take a long time, and relapse is common. If the person feels extremely discouraged, be sure to tell the doctor immediately so that the person can get immediate help.

In some cases, people who have an eating disorder may feel suicidal.

• Warning signs of possible suicide in children and teens can include being preoccupied with death or suicide, giving away belongings, withdrawing, being angry, or having failing grades.
• Warning signs and possible triggers of suicide in adults can include alcohol or substance abuse, depression, giving away belongings, a recent job loss, or divorce.

If you or someone you know shows warning signs of suicide, seek help immediately.

Bulimia is different from anorexia. People with anorexia weigh 85% or less of their normal body weight. But most people with bulimia are within their normal weight range. Some people who have anorexia make themselves vomit, but this is a different eating disorder. For more information, see the topic Anorexia Nervosa.

What Happens

Bulimia can develop after a person has followed a very restrictive diet. Binging may also be triggered by a stressful event, when food gives you a sense of comfort. Feeling guilty and ashamed of binging can cause you to purge to avoid weight gain. This starts the cycle of binging and purging that becomes a habit.

As bulimia develops, you may not eat at the beginning of the day, but later you may binge to comfort yourself, especially at the end of a stressful day.

Vomiting causes the body to release endorphins-natural chemicals that make you feel good.¹ Eventually you may make yourself vomit even if you have not overeaten so that you can feel good. Soon, you lose control over the binge-purge cycle. Repeated vomiting, fasting, exercising too much, or misusing laxatives, diuretics, ipecac syrup, or enemas will eventually cause serious, long-term health problems.

After bulimia becomes a pattern, it is very difficult to return to normal eating without help. Unhealthy eating behaviors can continue for many years before a person seeks treatment.

If not treated, bulimia can lead to serious, long-term health problems. It is common for people to hide the condition from others for years. By the time others discover the disorder, many people with bulimia already have serious problems. These range from mild to severe, depending on the type of purging behaviors and how long they have continued.⁵ Health problems caused by bulimia include:

• Tooth decay, toothaches, swollen gums, gum disease (gingivitis), and erosion of tooth enamel. These are caused by acid in the mouth from vomiting.
• Osteoporosis.
• Electrolyte imbalances and changes in metabolism that can lead to heart problems, such as arrhythmia and even death.
• Dehydration, which can lead to weakness, fainting, or kidney damage.
• Inflammation or tears of the esophagus, which may cause bloody vomit.
• Swollen salivary glands.
• Fainting or loss of consciousness, usually because of low blood pressure.
• Abnormal heartbeat (arrhythmia).
• Low body temperature.
• Suicide risk when feeling discouraged about having bulimia or a relapse or about ongoing body image issues.
• Long-term problems with bowel movements because of laxative abuse.

Overuse of medicine (such as ipecac syrup) to cause vomiting can lead to diarrhea, weakness, low blood pressure, chest pain, and difficulty breathing. A person can die from prolonged overuse of these medicines.

Other mental health problems often occur along with bulimia, which may make treatment take longer or make bulimia more difficult to treat.⁴ These conditions include:

• Depression, which commonly occurs with eating disorders and increases related feelings of guilt, anxiety, and obsession.
• Substance abuse, which occurs in around one-fourth of those with bulimia.
• Borderline personality disorder, which more commonly occurs with bulimia than with other eating disorders.
• Anxiety and anxiety disorders.
• Obsessive-compulsive disorder.
• Social anxiety disorder or other phobias.
• Panic disorder or panic attacks.

Although bulimia is a long-term disorder linked to serious health problems, it can be successfully treated. About half of people with bulimia recover completely with treatment. More than 9 out of 10 people who seek treatment for bulimia get better.⁶

Although treatment is usually successful, bulimia is a long-term disorder, and setbacks can occur. A return of symptoms (relapse) is especially common if a person continues to diet or have rituals related to food (such as planning the day around a time to binge) and is not sure that he or she is ready to change.⁷ But with ongoing treatment and patience, most people can eventually overcome bulimia.

Bulimia among teens with type 1 diabetes is becoming more common. These teens often lose weight before their diabetes is discovered, then quickly gain weight when treatment begins. Some learn that they can lose weight by skipping insulin doses. This causes poor control of their diabetes and can result in serious problems that can lead to blindness or kidney failure.

What Increases Your Risk

The risk of developing bulimia or another eating disorder is greatest if a person:^{3, 2}

• Has a biological parent, brother, or sister who has an eating disorder or who is overweight or obese.
• Has a family history of mood disorders, such as depression.
• Has a family history of substance abuse.
• Is overweight and starting a restrictive diet.
• Has certain personality traits such as perfectionism.
• Struggles with cultural and social factors such as admiring thinness.

When To Call a Doctor

Call your health professional immediately if you or someone you care about has been diagnosed with bulimia and now:

• Is not able to pass urine.
• Notices that his or her heart skips beats or beats slower than normal.
• Has severe abdominal pain, is vomiting up blood, or has black, sticky stools that look like tar. These signs may mean that there is bleeding in the digestive tract .

Call your health professional to discuss bulimia if you or someone you care about:

• Binges and then purges to get rid of food.
• Is concerned about weight and embarrassed by eating behaviors.
• Shows signs of an eating disorder, such as secretive eating habits, a preoccupation with body image, or an unhealthy appearance.

Watchful Waiting

Taking a wait-and-see approach (called watchful waiting) is not appropriate if you think you or someone you know may have an eating disorder. Call a doctor or an eating disorder hotline to discuss your concerns and learn what you can do to help.

Who To See

Bulimia may be diagnosed and treated by the following health professionals:

• Family medicine physician
• Psychiatrist
• Psychologist
• Physician assistant
• Nurse practitioner
• Licensed mental health counselor
• Registered dietitian

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Self-check: Do I have an eating disorder? Answer these five simple questions to see whether you may have an eating disorder:

Medical check: There is no single test that can diagnose bulimia or any other eating disorder. But these illnesses may have a visible effect on your health and eating habits.

If your doctor thinks that you may have an eating disorder, he or she will check you for signs of problems caused by your diet, such as malnutrition or starvation. He or she also may ask questions about your mental well-being. It is common for a treatable mental health problem (such as depression, anxiety, or obsessive-compulsive disorder) to play a part in an eating disorder.

Common exams and tests for a possible eating disorder include:

• Questions about your medical history, including your physical and emotional health, both present and past.
• A physical exam to check your heart, lungs, blood pressure, weight, mouth, skin, and hair for diet problems.
• Screening questions about your eating habits and how you feel about your health.
• A mental health assessment to check for depression or anxiety.
• Blood tests to check for signs of malnutrition, such as low potassium levels or other chemical imbalances.
• X-rays, which can show whether your bones have been weakened (osteopenia) by malnutrition.

A person can have bulimia and be underweight, average weight, or overweight. Most people with bulimia are within their normal weight range. Many binge in secret and deny that they may have a problem. These factors can make bulimia hard to diagnose.

People with bulimia often seek medical care for related health concerns, such as fatigue or stomach problems caused by repeated vomiting.

Early Detection

Early, accurate diagnosis and treatment of bulimia can decrease the chances of long-term health problems and even death in severe cases. Unfortunately, there is no routine screening for eating disorders. It is common for a person with bulimia to try to hide symptoms, which can make it difficult to detect. Most often a loved one thinks that there is a problem and seeks help for bulimia. It is common for a person to have bulimia for a long time and to develop serious health problems before anyone realizes that the person has the disorder.

Treatment Overview

Treatment for bulimia involves psychological counseling, and sometimes medicines such as antidepressants. Treatment does not usually require staying in the hospital, although this is sometimes needed. Both professional counseling and antidepressant medicine can help reduce episodes of binging and purging and help you recover from bulimia. Both are long-term treatments that may require weeks or months before you notice significant results. You may need treatment with counseling and possibly medicines for more than a year.

Bulimia that occurs with another condition may take longer to treat, and you may need more than one type of treatment. If you have another condition that commonly occurs with bulimia, such as depression or substance abuse, your doctor may want to treat that condition first.

People who seek treatment for bulimia or another eating disorder may have other health problems caused by the disorder. If you have had bulimia for a long time without treatment, or if you have used substances such as laxatives, diuretics, or ipecac syrup to purge, then you may have a health problem such as dehydration that needs treatment first. In serious cases, these conditions related to bulimia may require you to spend time in the hospital.

Initial treatment

Initial treatment depends how severe the bulimia is and how long you have had it.

If you have no other conditions that need treatment first, then treatment for bulimia usually consists of:

• Psychological counseling, such as cognitive-behavioral therapy (CBT). This often includes nutritional counseling to change certain behavior and thinking patterns. The goals of CBT are to teach you to:
  • Eat three meals and two snacks a day and avoid unhealthy diets.
  • Reduce concern about your body weight and shape.
  • Understand and reduce triggers of binge eating by examining your relationships and emotions.
  • Develop a plan to learn proper coping skills to prevent future relapses.
• Medicines. Antidepressants, such as fluoxetine (Prozac, for example), are sometimes used to reduce binge-purge cycles and relieve symptoms of depression that often occur along with eating disorders.

Ongoing treatment

Continuing treatment will depend on the how long you have had bulimia and how severe it is. Continuing treatment usually consists of:

• Psychological counseling, such as interpersonal therapy (IT) or cognitive-behavioral therapy (CBT). The goals of CBT are to teach you to:
  • Eat three meals and two snacks a day and avoid unhealthy diets.
  • Reduce concern about your body weight and shape.
  • Understand and reduce triggers of binge eating by examining your personal relationships and emotions.
  • Develop a plan to learn proper coping skills to prevent future relapses.
• Antidepressant medicines. Antidepressants can help lower the number of binge-purge cycles you have and may also be used to treat another related condition, such as depression or anxiety.

Treatment if the condition gets worse

If you develop other health problems such as dehydration or an esophogeal tear because of bulimia, you may need to stay in the hospital or in an eating disorder treatment facility.

Sometimes people with bulimia get discouraged because recovery can take a long time and relapse is common. If you or the person with bulimia feels very discouraged or feels suicidal, call a doctor or other health professional immediately to get help.

What To Think About

Treatment with an antidepressant medicine alone may not be enough. The most effective treatment for bulimia may be a combination of psychological counseling and antidepressants.⁸

Eating disorders are difficult to treat. Recovery may take months to years. The sooner treatment begins, the better the chance for a full recovery.

Unfortunately, many people don't seek treatment for mental health problems. You may not seek treatment because you think the symptoms are not bad enough or that you can work things out on your own. But getting treatment is important.

If you need help deciding whether to see your doctor, see some reasonswhy people don't get help and how to overcome them.

Prevention

There is no known way to prevent bulimia. Early treatment may be the best way to prevent the disorder from progressing. Knowing the signs of bulimia and seeking immediate medical care can help prevent long-term health problems caused by bulimia.

There are many ways that adults can help children and teens develop a healthy view of themselves and learn to approach food and exercise with a positive attitude. Doing this may prevent some children and teens from developing this disorder. See tips for developing:

• A healthy view of self and others. Teach children to take good care of their bodies. Avoid making comments that link being thin to being popular or healthy.
• A healthy approach to food and exercise. Avoid punishing or rewarding your children with food. And be a good role model for healthy eating and exercising.

Home Treatment

Home treatment is very important for people who have bulimia. You will set individual goals along with your doctor, nutritionist, and professional counselor. Some of these goals may include:

• Practicing emotional self-care. Don't blame yourself for your condition. Pace yourself, and try to spend time with other people who care about you.
• Taking one day at a time. Remember that your goal is to feel better with each passing day.

Family members will also need to support the person's goals for healing. Learning about the disorder will be helpful for the entire family.

• Avoid guilt and self-blame. Do not look for the reason for the disorder. Work toward changing things for the better.
• Show support of a loved one who has bulimia. Offer support if the person gets discouraged about how long treatment is taking. Listen to his or her feelings.

Medications

Medicines such as antidepressants may reduce the frequency of the binge-purge episodes of bulimia. They may also be used to treat other mental health problems, such as depression, that often occur along with bulimia. And you may need antacids to decrease stomach acid or bulk laxatives such as Citrucel to replace the overuse of more harsh laxatives.

Medication Choices

Antidepressant medicines are used to reduce the frequency of binge-purge cycles and treat any related depression or anxiety.

What To Think About

Sometimes several antidepressant medicines are tried before finding the one that works best. Treatment with medicines is more effective when combined with psychological counseling, which includes nutritional counseling.⁹

Surgery

There is no surgical treatment for bulimia.

Other Treatment

Psychological counseling. Several types of counseling may be useful in treating eating disorders. The two most proven types are:

• Cognitive-behavioral therapy (CBT). CBT teaches the person to understand the triggers of binge eating and to develop coping skills.
• Interpersonal therapy (IT). IT helps the person examine the relationship between interpersonal conflicts and symptoms of bulimia.

Other therapies that may be helpful include:

• Nutritional counseling, which teaches the person to eat three meals and two snacks a day and to avoid unhealthy diets.
• Dialectical behavior therapy, which is a long-term approach that focuses on helping the person regulate emotions. Coping better with life's challenges and negative emotions should help you decrease the binge-purge behaviors.
• Group counseling, which may enhance individual therapy. Often it is helpful to speak with other people who have this condition.
• Family therapy. Family members can be very helpful to their loved one's recovery, especially for an adolescent with bulimia. Family therapy teaches about the disorder and ways to help.

Self-care programs. Organized programs that provide self-help materials, such as manuals or computer-based activities, may be useful in treating eating disorders. But most people who have an eating disorder also need counseling and possibly medicine.

Stress management techniques. Although it is not part of the treatment of bulimia, relieving stress can help during recovery. Techniques for managing stress include:

• Exercising. Regular, but not excessive physical activity is one of the most effective stress management techniques.
• Writing. Research shows that expressing yourself in writing can be a very effective way to reduce your stress level.¹⁰
• Expressing your feelings. Talking, laughing, crying, and expressing anger are normal parts of the emotional healing process.
• Doing something you enjoy. A hobby or other healthy leisure activity that is meaningful to you can help you relax. Volunteer work or work that helps others can be a powerful stress-buster.
• Learning body-centered relaxation. This includes breathing exercises, muscle relaxation exercises, massage, aromatherapy, yoga, and the traditional Chinese relaxation exercises called tai chi and qi gong.
• Learning mindfulness activities. These include learning how to relax your body through self-hypnosis, meditation, imagery exercises, listening to relaxing music, and using humor to reduce stress.

For more information on stress reduction, see the topic Stress Management.

Other Places To Get Help

Organizations

Related Information

• Anorexia Nervosa
• Binge Eating Disorder
• Depression
• Depression in Children and Teens
• Healthy Eating

References

Citations

1. Sadock BJ, et al. (2005). Eating disorders and obesity. In Kaplan and Sadock's Pocket Handbook of Clinical Psychiatry, 4th ed., pp. 225-235. Philadelphia: Lippincott Williams and Wilkins.

2. American Psychiatric Association (2000). Eating disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 583-595. Washington, DC: American Psychiatric Association.

3. Kreipe RE, Birndorf SA (2000). Eating disorders in adolescents and young adults. Medical Clinics of North America, 84(4): 1027-1049.

4. Gwirtsman HE, Ebert MH (2000). Eating disorders. In MH Ebert et al., eds., Current Diagnosis and Treatment in Psychiatry, pp. 421-429. New York: McGraw-Hill.

5. Committee on Adolescence, American Academy of Pediatrics (2003). Policy statement: Identifying and treating eating disorders. Pediatrics, 111(1): 204-211.

6. Hay P, Bacaltchuk J (2006). Bulimia nervosa, search date June 2006. Online version of Clinical Evidence (15).

7. Halmi KA, et al. (2002). Relapse predictors of patients with bulimia nervosa who achieved abstinence through cognitive behavioral therapy. Archives of General Psychiatry, 59(12): 1105-1109.

8. Bacaltchuk J, et al. (2007). Antidepressants versus psychological treatments and their combination for bulimia nervosa. Cochrane Database of Systematic Reviews (2).

9. Steering Committee on Practice Guidelines, American Psychiatric Association (2006). Treating eating disorders: A quick reference guide. Available online: www.psych.org/psych_pract/treatg/quick_ref_guide/EDs_QRG.pdf.

10. Seymour DJ, Black K (2002). Stress in primary care patients. In FV DeGruy III et al., eds., 20 Common Problems in Behavioral Health, pp. 65-87. New York: McGraw-Hill.

Other Works Consulted

• Agras WS (2005). The eating disorders. In DC Dale, DD Federman, eds., Scientific American Medicine, section 13, chap. 9. New York: WebMD.

• Anderson AE, Yager J (2005). Eating disorders. In BJ Sadock et al., eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 8th ed., vol. 1, pp. 2002-2021. Philadelphia: Lippincott Williams and Wilkins.

• Hay PJ, Bacaltchuk J (2007). Psychotherapy for bulimia nervosa and binging. Cochrane Database of Systematic Reviews (2).

• Nakash-Eisikovits O, et al. (2002). A multidimensional meta-analysis of pharmacotherapy for bulimia nervosa: Summarizing the range of outcomes in controlled clinical trials. Harvard Review Psychiatry, 10(4): 193-211.

• Sadock BJ, et al. ( 2007). Bulimia nervosa and eating disorder not otherwise specified. In Kaplan and Sadock's Synopsis of Psychiatry, Behavioral Sciences/Clinical Psychiatry, 10th ed., pp. 735-739. Philadelphia: Lippincott Williams and Wilkins.

• Yager J, et al. (2006). Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd ed. Arlington, VA: American Psychiatric Association. Also available online: www.psych.org/psych_pract/treatg/pg/EatingDisorders3ePG_04-28-06.pdf.

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