Chaosophy2000

Asklepia Monograph Series

EATING DISORDERS
and the
CONSCIOUSNESS RESTRUCTURING PROCESS

by Iona Miller and Graywolf Swinney
Asklepia Foundation, ©2000

ABSTRACT:  Typical treatment for eating disorders involves ego building and cognitive redecision therapy; existential systems-oriented therapy.  But eating disorders are holistic dis-eases.  The root of the disorder is a mistake in self-image.  They reveal the relationship of a self to the world who either can’t get enough, or for whom any input is too much.  Since we must all eat to live, being out of balance with food means being out of balance with nature.  The CRP process dissolves old patterns of self-image, of relationship with food, and rebuilds ego by first restructuring consciousness at the sensory root or primordial level.  REM journeys facilitate creative self-organization.
CRP for disordered eating is not just for those with clinical disorders, or even food cravings for carbohydrates, fats, or sweets.  Poor dietary and sleeping habits lead to hypoglycemia, subclinical depression, fatigue, insomnia, and poor concentration, disrupt daily life, strain relationships, and even jeopardize careers.  Self-esteem, self-control, mood, and eating are intertwined, so what a person eats or feels is wrongly metabolized.  What we eat affects whether we are happy, sad, irritable, moody, alert, or sleepy.  If you want to feel your best, you have to eat your best.  Children can also benefit from CRP: 1 out of 3 children are overweight and in danger of obesity; children are 30% heavier than they were 10 years ago.
Keywords:  Eating disorders, anorexia, bulimia, obesity, dreams, dreamwork, REM, consciousness, binging and purging, eating behavior, psychotherapy, mood and food, hypoglycemia, alcoholism, psychosomatics, sugar blues, cravings, nutrition, depression.

WHAT IS AN EATING DISORDER?

Gross disturbances in eating behavior are characterized as eating disorders.  Clinical syndromes relating to food include anorexia, bulimia, and obesity.  They are all marked by an uncontrollable obsession with diet and weight.  This preoccupation with food can lead to such outward signs as poor complexion, dull hair, eroded teeth, or tired eyes.  Sometimes an eating disorder is secondary, resulting from substance abuse or depression.

For both the starver or the binger, the disease becomes the identity.  Regardless of the eating disorder, it manifests in increased feelings of anxiety, depression, alienation, helplessness, fear of fat, and vulnerability to impulsive behaviors.  Even though they may have begun with simple dieting, often these disorders are progressive and manifest a distinct set of signs.  Whatever begins the dieting spiral, imbalances created in the body’s chemistry are the major reasons why the eating disorders progress.  There is a natural nerve-chemical basis for the eating pattern that can eventually become all-consuming.

Subclinical disorders may exist in those of normal weight whose lives are marked with obsessive thoughts of food and with strong desires to eat, coupled with severe, controlled restraint.  Poor diet is related to moodswings, fatigue, stress, hostility, depression, poor concentration, memory loss, and sleep problems that can interfere with enjoying life.  Dietary chaos is harmful; wildly fluctuating blood sugar can lead to a variety of diseases.

What you eat affects thinking profoundly:  (1) the level of neurotransmitters in the brain that regulate mood and mental processes; (2) development and maintenance of brain cell function and structure; (3) the insulating sheath around nerve cells that speeds messages; (4) the level of enzymes which enhance brain functions; (5) the amount of oxygen the brain receives; (6) the rate of accumulation and removal of cellular debris; (7) the ability of brain cells to transmit electrical messages.

Links between mood, eating patterns, and nerve chemicals are very strong.  Even if psychological issues initiate the condition, hormones and nerve chemicals are turned topsy-turvy as a result of eating disorders.  Disorders might be fueled by neurotransmitters gone amok because of dieting spirals (Somer, 1995).

Serotonin and endorphins are powerful shapers of personality and mood and have been associated with food-mood problems, from food cravings to PMS and Seasonal Affective Disorder (SAD).  Self-starvation and binge eating are fueled by powerful internal chemicals, which though out-of-balance can return to normal levels.  Low serotonin levels are implicated in binging and purging; whereas elevated serotonin may suppress appetite in anorexia.  Endorphin levels are elevated after a purge.  Anorexics are addicted to the endorphin-induced rush that comes from dieting and starvation.

Subclinical manifestations of disordered eating include insomnia, “the blues,” yo-yo dieting, food abuse, addictive overeating, and uncontrollable food cravings for fats, sugars, or carbohydrates.  They become problematical when self-esteem, self-control, mood and eating become entwined and rebound.  There are links between sugar and the brain chemicals that influence who we are, what we do, and how we think and feel.

Food abuse, or emotional overeating has antecedents which lead to behaviors which have real consequences.  Reasons other than simple hunger for nourishment precede this eating.  Restrictive diets can swing the pendulum to binges which follow, and fear of food can develop.  Irrational beliefs are part of the process and include all-or-nothing thinking, overgeneralization,, shoulda-coulda, labeling, etc.  Misconceptions include “Food is love;” “Food is responsbility;” “Food is reward;” “Food is fun.”

Blood sugar levels directly affect our appetite and energy level.  Excess caffeine can lead to chronic sleep deprivation.  Drinking is another source of toxic intake: alcohol and other depressants suppress a phase of sleep called REM, during which most of our dreaming occurs. Dieting can leave you sleepless.  Less REM sleep is associated with more night awakenings and a more restless sleep.  Alcoholics REM sleep is low and they spend little or no time in the deepest phase called delta sleep.

Some treatments for full-blown eating disorders focus on underlying dynamics and stress the importance of individual therapy.  Some practitioners recommend long-term dynamic psychotherapy, others reducing symptoms immediately through the use of brief strategic therapy.  Others focus on family dynamics and stress the usefulness of treating the family system.  Obviously, there are approaches to medical management of these disorders.

Simple obesity is conventionally considered a physical disorder, not generally associated with any distinctly psychological or behavioral syndrome, however psychological factors may have influenced its etiology.  Psychological factors can affect physical condition.

Anorexia and bulimia are apparently related disorders.  Anorexics develop a fear of food and a horror at the act of eating.  Confined to a rigidly ritualized pattern of behavior that leads them toward voluntary starvation, they deny that they are too thin, even to the point of death.  Its issues are control and dependency needs, perfectionism, and boundaries.  Anorexia is fatal in 5% of those with the chronic disorder.

Diagnostic criteria (DSM-IV) for anorexia include the following:

A.  Refusal to maintain body weight over a minimal normal weight for age and height, for example weight loss leading to maintenance ob body weight 15% below that expected; or failure to make expected weight gain during period of growth, leading to body weight 15% below that expected.

B.  Intense fear of gaining weight or becoming fat, even though underweight.

C.  Disturbance in the way in which one’s body weight, size, or shape is experienced, e.g., the person claims to “feel fat” even when emaciated, believes that one area of the body is “too fat” even when obviously underweight.

D.  In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (amenorrhea).

Anorexia nervosa is a condition usually affecting adolescent and young adult females in which the patient may literally starve herself to death, even though experiencing intense desires to eat.  She usually expresses fear of gaining weight and denies that her emaciated condition is a problem.  The condition is frequently associated with schizophrenia.  33% of parents have a diagnosis of primary affective disorder, more prevalent among female relatives of patients.

In the relentless pursuit of thinness, the anorexic may use laxatives, enemas, and diuretics to attain her elusive image of perfection.  Street drugs, such as cocaine, speed, or heroine may create a chemically induced anorexia by disordering eating and sleeping patterns and initiating a chemical spiral of appetite suppression.

There are obsessive-compulsive antecedents to the onset of relentless anorexia:  (1)  The (pre) anorexic experiences her parent(s) as depleted, exhaused, dependent (upon her), and insubstantial. (2) She develops fear of abandonment and mistrust. (3)  She defends against these fears by becoming contemptuous and angry. (4)  She becomes afraid of and ashamed of her feelings of contempt and anger and believes she may damage her insubstantial parents.

She represses her feelings and becomes overpleasing, overcompliant, even controlling with her own nurturing behavior.  She vicariously enjoys the care she offers others. (5)  She turns to external order to feel secure, ritually and compulsively arranging her possessions.  Since she lacks existential trust, all decisions become crucial and fearfully made.  (6) Rigidly executed rituals provide a sense of safety and increase in number (Levenkron, 1982).

Anorexia’s companion disease, bulimia, can be separate from anorexia or can coexist with it (bulimarexia).  In bulimia, the horror of food takes a weird turn in the form of uncontrollable, usually secretive, binging.

The bulimic can consume between 2,000 to 50,000 calories at a sitting, then the huge amount of food is vomited back up, stressing the digestive system and whole body.  Impulses to binge and purge bring about basic physiological changes, including dehydration, electrolyte imbalance, hypoglycemia, dental and gastrointestinal problems, and insomnia.  DSM-IV criteria for bulimia nervosa include these characteristics:

A.  Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time.

B.  A feeling of lack of control over eating behavior during the eating binges.

C.  The person regularly engages in either self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain.

D.  A minimum average of two binge eating episodes a week for at least three months.

E.  Persistent overconcern with body shape and weight.

Binge-eating is usually chronic and intermittent with periods of normal eating.  Bulimics plan eating binges where food is eaten secretly or as inconspicuously as possible.  It is gobbled down rapidly with little chewing.  Abdominal discomfort, social interruption, induced vomiting or sleep may end the binge.

The binge/purge cycle brings on depression and disparaging self-criticism.  Purging may burn and rupture the esophagus and over time lead to a severe medical problem and internal bleeding.  Laxatives and diuretics are abused in attempts to control weight fluctuations.  Bulimics are also at risk for other addictive behavior involving sedatives, amphetamines, cocaine, or alcohol.

CONVENTIONAL TREATMENT OF EATING DISORDERS

A typical eclectic two year treatment program of interdisciplinary therapies and interventions takes place in three phases: (1)  the initial stage of first six months, (2) the middle stage of six to eighteen months, and (3) the final stage 18 months to two years.

The treatment program for anorexia (Andrewartha, 1982) contains the following:

1.  Immediate confrontation of the suicidal nature of the anorexic with simultaneous defining of the food issue as a symptom of a control struggle.

2.  Immediate definition of the treatment program being two years with implicit reliance on the therapist for that time.

3.  Close and continuous medical supervision.

4.  The use of male/female co-therapy team.

5.  Intensive therapy (4 to 6 times a week for the first 6 months with a gradual reduction to weekly group sessions).

6.  Minimal involvement with the family of origin or their substitutes but intensive family therapy with the parent projection in the client’s head.

7.  Considerable regressive work utilizing reparenting principles to achieve a healthy separation.

8.  Major redecisions around the above script issues.

9.  Lots of humor.

Therapy for all eating disorders revolves around redefining food issues, control issues, weight beliefs, self-worth, and fat issues.

Medical management for anorexia and bulimia includes risk assessment, current medical condition, and anticipated behavior.  There is close collaboration between the internist and the psychotherapist.

Management of refeeding is initiated in high risk patients with 50% weight loss, symptomatic hypoglycemia, hypothermia, significant EKG abnormalities, and clumsiness.  When voluntary feeding is insufficient, by tube or intraveneously.  While anorectics can be extremely frustrating, the recoveries possible are as spectacular as any in medicine.

EATING DISORDERS AND TRANSACTIONAL ANALYSIS

TA approaches eating disorders with a variety of perspectives, an existential systems-oriented treatment.  Some clinicians use the Redecision model, while others use Reparenting techniques, or Berne’s emphasis on social control.  Work is done in both individual and group settings.  Family therapy and educational programs, and group therapy programs are designed specifically for eating disorders they address.

The most important questions here are:  (1)  What are some of the dynamics which underlie the various problems related to food and eating? and;  (2)  What enables people with symptoms of anorexia, bulimia, or obesity to decide to change?

In treating people with eating disorders, it is important to recognize and deal with fat issues as well as eating issues.  Fat issues and eating issues often support different script decisions, which show up at three levels of impasse.

Recognizing and dealing with fat issues (Griffin, 1985), negative body image, and the self-loathing that accompanies this image is an important part of treatment.  Fat issues will not magically disappear once a person starts eating appropriately.  In fact, these unresolved fat issues will probably prompt a relapse into old patterns of binge eating and starvation.  All this is linked to boundary issues, and the meaning of food and size.

Common beliefs which contribute to the misuse of the eating function include perfectionism, perceiving the world in either/or dichotomies, if-then perils, and perceiving self in detrimental comparisons.

Since food must be mastered several times a day, it is important that the client see herself as responsible for her cure.  Anorexics steadfastly deny and minimize the severity of their illness.  They can be uninterested in or resistant to therapy.

Control must be experienced as emanating from inner sources if the bulimic is to become able to encounter food with pleasure and confidence (Vognsen, 1985).  The therapist avoids direct attacks on the problem behavior, and doesn’t try to end bulimic behavior by advice, exhortation, or confrontation.

Putting an end to habitual binging and purging is not unlike changing other addictive behavior.  They must be persuaded to stop the practice in question and then be encouraged through the ensuing period of discomfort and occasional panic.  Treatment changes perceived helplessness, allowing spontaneous or willfull reassertion of control of eating.

Although anorexia, bulimia, and obesity have apparently different symptomology, they are closely related through common underlying problems stemming from injunctions and constellation of early decisions.  Eating disordered individuals often have extremely low self-esteem and feel powerless, often having the sense that autonomy and a clear sense of self was thwarted in early childhood.  They have fears of abandonment and rejection (Solomon, 1986).

Injunctions revolve around developing an autonomous self:  Don’t Feel, Don’t Be You are primary.  Bulimics frequently have double scripts of contradictory messages: Hurry Up and Grow up at an early age, then Don’t Grow Up as an older child.  Anorexics get the admonishment Don’t Exist, Don’t Be Sexual and counter-injunctions to be perfect and to please and take care of others.  The obese get Don’t Be You and Don’t Be Sexual.

Active listening to the client’s general needs is essential, rather than enforcing an agenda.  Food and Weight related talk varies with the patient’s nutrtional and general physical state.  Failure to confront nutritional issues may imply to the patient that the therapist fears the disease and is abandoning her to its effects.

It is paramount the therapist does not become obsessive with the patient about eating.  Anorexics frequently engage others in endless discussions of food, reinforcing the precoccupation with eating and avoiding discussing feelings.  She thus attempts to overpower the therapist.  Extorting promises to gain weight are counterproductive.  Free time is potential time to obsess and become anxious.  Patients’ big fear is that refeeding will start them on an out-of-control gaining spurt.

The most counterproductive behaviors by the therapist are, first, dependent communications, and second, abandoning communications from therapist to client.  Dependent communications seek reassurance from the patient to the therapist that therapy is working; abandoning statements are those that ask her to assume premature autonomy.  These kinds of statements replay parental behavior, and imply the therapist is also insubstantial and cannot help her.  This leads to retreat into the compelling magical system that is her illness (Levenkron).

EATING DISORDERS AND CONSCIOUSNESS RESTRUCTURING

Deepak Chopra (1989) has revisioned eating disorders from the holistic perspective:

“To explain this paradoxical illness, one has to drop the distinction between mind and body and think of one system, the ‘bodymind.’  This is because an eating disorder is a holistic disease, the cruel opposite of holistic health.”

Whether a person is compulsively too fat or too thin does not depend primarily on how much food she takes in.  The drive to embody a particular pattern comes from the existential sensory self-image, which patterns the bodymind.  A memory is picked up and stored in the body, in a particular conformation.

It is generally recognized that for the chronically obese, diets do not solve the problem because the brain of the person is always sending out overpowering signals for too much food.  Unless some change takes place at a very deep level, the messages stay the same and are triggered compulsively as a self-defeating tactic.  The intellect is powerless to change these distortions in self-image.  One part of the personality struggles to maintain rationality while another creates wildly irrational impulses.

How we react to thoughts of food set up either waves of revulsion or desire, or cycles of repulsion and gluttony.  The thought and the reaction come together, and there is no place to drive a wedge between them.  The thought and the molecular changes it creates are one.

The thought is the molecule; the molecule is the thought.  And this irresistible impulse constitutes the person’s whole inner reality.  She is her disease for the moment.  Struggles to change this thought are futile and patients feel guilt over “causing” their own disease.

But there is a third component in this process which is silence that lies deeper than thought, and it is there that a cure may be found.  The person’s sick memory has gotten into her chemical system.  The nonmaterial memory becomes embodied there in the whole person.  Memory has built some matter around itself, forming a specific pattern.  Your body is thus the place your memory calls home.

Like other addictions, food addiction is a distorted memory, one that subverts the natural rhythms of life including eating, elimination, and sleeping.  With all the chaotic shifts of fluids and chemistry, thinking and mood vary substantially, leading to functional difficulties.

Many clients have come for CRP for seemingly unrelated reasons (other adjustments, alcoholism, etc.) and found that as a side-effect, often lifelong-struggles with food and weight changed for the better automatically.  Their tastes and desires just automatically changed to more healthy patterns as their systems became more harmonious and in balance.

The commonality between all the overcontrolled or out-of-control eating disorders (anorexia, bulimia, obesity) is a sensory failure to perceived and maintain an optimal level for their blood sugar, so that cells can get the nourishment and energy they need.

Other nutritional deficiencies, such as B vitamins and zinc aggravate hypoglycemia.  Even Mercury from dental fillings is a culprit.

Rising and falling blood sugar levels create mood swings that contribute to general emotional chaos and feelings of incompetence.  Independent studies show that starvation leads to obsessive thinking, accelerated by the act of dieting, leading to a spiral of malnutrition and compounded obsessive thinking.  This disordered thinking is the first area therapy must affect.

This sensory failure extends to create confusion about the boundaries of the body.  All their thoughts and feelings are filtered through a brain starved by disordered over- and undereating.  What possibly links improvement in related conditions such as alcoholism is once again, a link with the metabolism of sugar in the body.  The body treats refined sugar and alcohol in a similar manner -- toxic shock.

Paradoxically, low blood sugar causes “neurosis” and neurosis causes low blood sugar (Fredericks, 1985).  Low blood sugar creates a plethora of psychosomatic symptoms: sinus trouble, allergies, constipation, dandruff, poor circulation, digestive disturbances, forgetfullness, palpitations of the heart, rapid pulse, muscle pains, numbness, blurred vision, muscle twitching, itching and crawling sensations, gasping for breath, blotchy skin, sensitivity to sunshine, and falling hair.

Emotional troubles include nervousness, sleeplessness, being edgy and subject to uncontrollable fits of temper, difficulties in concentrating, hypochondria, mild agoraphobia, and a completely unjustified, constant feeling of  “something terrible about to happen.”

Many of these symptoms arise because blood sugar is too low to support the nervous system and the brain.  Low blood sugar, and an overactive pancreas, can turn an otherwise balanced person into an apprehensive hypochondriac.  It creates intolerable anxiety, unjustified fear, internal feelings of shakiness, nightmares, weak spells and insomnia (awakening 3-4 hours after falling asleep and being unable to return to sleep).

It can imitate or aggravate epilepsy, migraine headache, peptic ulcer, rheumatoid arthritis, delinquency, and asthma.  It can directly cause alcoholism, and could possibly lead to drug addiction.  Alcoholism inevitably will worsen low blood sugar and intensify nutritional deficiencies in a vicious circle.

Low blood sugar itself can cause compulsive drinking!  A strong desire for sugar is characteristic of alcoholics who alternate between periods of sobriety and abysmal intoxication.  They eat enormous quantities of candy while sober -- always when sober, never when drinking.  Many are able to break their habit once hypoglycemia has been treated.

All alcoholics are subject to low blood sugar, if not as a cause, as a result of the substitution of alcohol for food.  Treating it may benefit any compulsive drinker, even if cure of the compulsion does not follow--which it may.

Severity of the dysfunction is irrelevant as even little deficits can create big problems.  Mild hypoglycemia can create severe symptoms; severe hypoglycemia can manifest as comparatively mild symptoms.  The overactive pancreas produces the hormone that helps us to burn sugar, and the amount at work in the body is critical.  Too little of this insulin results in diabetes.  But the overreactive pancreas makes too much insulin, and can produce shock, dizziness, cold sweats, irritability, shakiness, anxiety and even collapse.

All forms of sugars (and alcohol) stimulate the overactive gland even more, and to compound it, the condition creates a craving for sweets.  Diabetes can result when an overactive pancrease exhausts itself.  But the misbehavior of the gland is only a symptom, too, rather than a cause, and we still don’t know what makes it go berserk.  Continual stress is a probable culprit in initiating hyperactivity.  Anxiety can touch off low blood sugar and forms a vicious circle since low blood sugar causes anxiety.

Consumption of more than a hundred pounds of sugar a year looms as the most probable cause.  The average person eats a teaspoonful of sugar every thirty-five minutes, twenty-four hours a day; almost 1 cup daily; 104 pounds per year!

One form of low blood sugar arises from and causes monotony, boredom, a sense of aimlessness, and lack of a feeling of achievement.  According to Fredericks, a “flat glucose-tolerance curve,”

“is the disturbance in sugar metabolism that comes about when a person is, for instance, forced into an occupation in which he finds neither zest nor challenge.  The tension is low-grade; so is the upset in the dynamics of the management of blood sugar. . .pre-hypoglycemia...when the person finds no challenge and no sense of achievement in pursuing his (inescapable duties); and the body responds to the deficit in mental and emotional challenge by not attuning itself to the demands made upon it, with the result that there is an imbalance created between the function of the adrenal glands, which elevate blood sugar, and the pancrease, which lowers it.”

“This results in a chronic half-starvation of the brain.  The sugar levels in the blood do not dip low enough to cause blackout, nor rise high enough to permit efficient function, and the person is only half-alive, existing in a twilight zone where constant fatigue is the symptom of his emotional sit-down strike.”

It would seem the body rebels against monotony and tedium and lack of fulfillment.  Lack of zest leads to a lack of sugar for the brain and constant mental and emotional fatigue result.  Lack of zest deprives the body of stimulation needed to keep the nervous system in tone, and this leads to lack of sugar which creates and compounds fatigue.  The question becomes, “Are you tired or are you tired of what you are doing?”  Young executives, who show the flat-curved hypoglycemia profile, feel trapped and complain of fatigue, loss of zest, and boredom.

When the pancreas is quieted, no longer overstimulated by sugars, the adrenals have the capacity to return to normal functioning.  The body can counter sudden deviations from the normal level of about two teaspoonfuls in the bloodstream.  However, it cannot tolerate a continued deviation--whether in the form of consistently overelevated blood sugar levels--or, what is even more threatening, consistently depressed blood sugar levels.

There are at least two people suffering silently from low blood sugar for every one affected by diabetes.  Even a fasting-overnight blood sugar test doesn’t reveal the daily swings in levels, so many go undiagnosed.  The pancreas has simply been oversensitized to sugar and is overactive producing insulin or underactive in producing glucagon, the hormone that is anti-insulin in its effect.

This is the response to too much prodding of the organ by the brain and the nervous system and to too much tension and anxiety, producing an imbalance of nervous impulses reaching the pancreas or a related disturbance of the function of the liver in meting out its stores of reserve sugar.  Black coffee pushes reserves of  sugar into the bloodstream, which challenges both pancreas and adrenals, causing low blood sugar.  Coffee with sugar is even worse.

It is easy to see how personality and behavior can be changed since the brain and nervous system are on a constant, stable, small supply of sugar.  But our systems were never meant to handle the overavailable high doses we get in modern life, from largely hidden sources.    Three times each minute, the brain completes a series of chemical reactions in which sugar is converted into energy.

CRP can effect changes at the quantum, neurological, and chemical level which can reinstate homeostasis.  Individuals find that they automatically change their eating patterns and their desires for certain kinds of foods once consciousness restructuring begins.

However, a little basic education in nutritional requirements goes a long way in correcting any nutrional disosrder, once the irrational aspects of the syndrome are being addressed.  Taking daily suppliments certainly doesn’t hurt, and can jump-start the psychological work tremendously by providing the body the raw materials it needs for its chemical factory.  We are indeed what we eat, and the maxim of the computer-age holds:  “Garbage in, garbage out.”

REFERENCES

Andrewartha, Graham, “Anorexia nervosa: three case studies of TA treatment,” Transactional Analysis Journal, Vol. 12, No. 2, April 1982.

Fredericks, Carlton, New Low Blood Sugar and You, Putnam Publishing Group: New York, 1985.

Griffin, Stephanie, “Eating issues and fat issues,” TA Journal, Vol. 15, No. 1, January 1985, pp. 30-36.

Levenkron, Steven, Treating and Overcoming Anorexia Nervosa, Charles Scribner’s Sons: New York, 1982.

Schiff, Jacqui, “Treatment of anorexia nervosa,” Transactional Analysis Journal, 7:1, January, 1977.

Somer, Elizabeth, FOOD & MOOD, Henry Holt and Company, New York, 1995.

Vognsen, Jack, “Brief, Strategic Treatment of Bulimia,” TA Journal, Vol 15, No. 1, January, 1985, pp.79-84.


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