Historically, eating disorders such as Anorexia Nervosa and Bulimia Nervosa were misunderstood to be a consequence of an individuals’ desire to be thin. However, it is now known that they are in fact distinct, self-maintaining psychological disorders with multiple causes. The purpose of this essay was to describe the various psychological causes, effects and treatments of eating disorders although it was also felt to be appropriate to acknowledge the physical, biological and social aspects of such disorders. Its purpose was also to raise the awareness of male eating disorders and demonstrate that such cases have been seen to increase. In order to gather appropriate and non-biased information a range of resources have been used. These include: factual literature, journals, studies, newspaper articles, sufferer’s personal accounts and notes taken from professional lectures. The extensive research confirmed that eating disorders are in fact psychological disorders and evidenced the fact that not only do males suffer too, the prevalence of reported cases has been seen to be increasing.
Eating Disorders: A Psychological Perspective
For some people, their lives are a constant battle between their diet, their appearance and their emotions; “with each pound lost, I was becoming more acceptable to the world” (Harvey, 2007). Eating disorders are often mentioned within the media but scarcely spoken about in great detail, which has resulted in stereotypes and misperceptions being made about what ‘eating disorders’ are as well as what they mean for the individual. One such stereotype is that sufferers are predominantly women who have the desire to be skinny. However, it is becoming increasingly recognised that eating disorders can develop in anyone and are often coping strategies for dealing with difficult emotions through gaining control over an aspect of an individual’s life.
Consequently, this essay aims to enhance people’s understanding of eating disorders by presenting a psychological account of their development, impact and treatment within individuals. This will be achieved by focussing on two eating disorders in particular, Anorexia Nervosa and Bulimia Nervosa, although other eating disorders will be considered where appropriate. Firstly, a history of these eating disorders will be presented leading to how they are conceptualised and defined today within the current diagnostic system. Secondly, this essay will discuss the potential causes of eating disorders in order to gain an understanding of the common underlying issues, which are potential contributing factors to the development of an eating disorder. Thirdly, the consequences of an eating disorder for both the sufferer and their family will be discussed before exploring an emerging awareness of eating disorders amongst men. Lastly this essay will present the treatments used today in the management of an eating disorder. It is hoped that this discussion of eating disorders from a psychological perspective will equip the reader with the knowledge and understanding required to challenge any previously held stereotypes and misconceptions of eating disorders.
Historically, the behaviours associated with today’s eating disorders were not uncommon, or pathologised. For example, there are numerous records of wilful, ritual fasting, which served specific purposes such as to receive some trance-like state that was a medium for sacred visions. Fasting was also used as a means of penance or purification (Bemporad, 1996). Purging was also present during the time of the Ancient Romans. Within this time it was not uncommon for the Ancient Romans to excuse themselves from a banquet, to purge and then return to continue feasting. It is also understood through Egyptian hieroglyphics that the Egyptians used purging as a safety measure against illness and would therefore purge monthly (Engel et al, 2007).
Therefore it can be seen that historically, behaviours such as fasting and purging were a part of society and therefore normalised by the social and cultural context that existed then. However society along with its cultural norms has changed rapidly. Accompanying these changes were changing views about peoples behaviour. For example, during the reformation era, women who starved themselves were thought to be possessed by the devil, later they were thought to be frauds seeking notoriety and lastly they were seen as being physically and mentally ill (Brumberg, 1988).
Accordingly, the first diagnosis of Anorexia Nervosa was in the case of a wealthy Roman female who starved herself for the sake of spiritual beliefs. However, the first official medical diagnosis was seen in England during the 1680’s in the case of a twenty-year-old female where it was said that sadness was the cause of her starvation (Engel et al, 2007). In 1874, Anorexia Nervosa (nervous loss of appetite) was given its name by physician Sir William Gull (Ogden, 2010, p211). He was the first to recognise that such conditions should be considered a mental illness (Engel et al, 2007). However it wasn’t until the 1930s that other professionals came to agree that eating disorders were often a result of an emotional or psychological struggle rather than being driven by the desire to be physically thin (Engel et al, 2007).
Today, there are a range of known eating disorders including: Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, Eating Disorder Not Otherwise Specified and exercise disorders such as, Bigorexia and Compulsive Exercising (Anorexia Athletica and Obligatory Exercise) (Nemours, 2013). These eating disorders each have their own set of diagnostic criteria, which are outlined within the Diagnostic and Statistical Manual of Mental Disorders (DSM). This framework is commonly used by professionals to diagnose and treat individuals with different types of eating disorders.
Anorexia Nervosa is an eating disorder based upon the control of the way an individual looks and the foods they eat. It is thought that sufferers of this disorder strive to be thin because it results in a sense of self-worth and acceptance (MFMER, 2012a); this belief is potentially a result of the media’s portrayal of the average person in society today. A sufferer of Anorexia Nervosa tends to be extremely cautious about the amount of calories they consume and their diets are often restricted. This is believed to provide the sufferer with a sense of control and provides a focus for their thoughts; distracting them from difficult emotions they may be trying to avoid. In terms of the official diagnosis of Anorexia Nervosa, the DSM states that there must be: the refusal to maintain a normal weight for the individual’s height and age, an intense fear of weight gain even though the individual is already underweight, distorted body image and the absence of a minimum of three consecutive menstrual cycles (APA, 1987, p.67). Women with a BMI lower than 17.5 and displaying physical or psychological aspects stated within the diagnostic criteria will be diagnosed with Anorexia Nervosa (Abraham & Llewellyn-Jones, 2001, p.28) and subsequently referred for treatment or therapy. Anorexia Nervosa is split into two types, purging and non-purging/restricting (Ogden, 2010, p.212). Non-purging anorexics solely restrict their diets whereas purging anorexics will restrict their diets and also binge on food and proceed to purge. It is thought that up to 50% of Anorexia Nervosa sufferers engage in binging and purging behaviours (Franco, ND). Common physical symptoms experienced by sufferers of Anorexia Nervosa include: severe weight loss, the growth of fine hair over the body, dizziness, low blood pressure, constipation, and loss of periods and a sense of tiredness but the inability to sleep (Beat, 2010). Psychologically, sufferers often develop inflexible and negative ways of thinking about themselves, believing that they are overweight or fat when in fact they are underweight. Behavioural symptoms may include secrecy and self-exclusion during meal times, quietness and withdrawal from social situations. As well as restricting their eating, sufferers may also become obsessive in checking the calorie content of food and their weight.
The development of Bulimia Nervosa is also recognised as a response to stressful life events (Abraham & Llewellyn-Jones, 2001, p.191) and difficult emotions but conversely, the individual is believed to hold fewer concerns about their physical appearance and the desire to be accepted via thinness. When suffering from Bulimia Nervosa it is thought that an individual engages in binge eating when they feel a build up of tension or stress, as it is believed to relieve them of these sensations (Abraham & Llewellyn-Jones, 2001, p.196). Although Bulimia Nervosa sufferers binge eat, they are also believed to understand that this type of disordered eating will result in weight gain. Sufferers therefore take measures to ensure that they avoid gaining weight and the most common measure taken is purging during or after a binge. This is done to prevent the absorption of energy and fats from food into the sufferer’s body (Abraham & Llewellyn-Jones, 2001, p.197). In addition to this strategy, between 75 and 90 percent of Bulimia Nervosa sufferers abuse the use of laxatives during and in between purges to assure themselves that the food consumed will not be absorbed as fat (Abraham & Llewellyn-Jones, 2001, p.197). It is also understood that many Bulimia sufferers choose to carry out a strict dieting regime between binges to avoid weight gain (Abraham & Llewellyn-Jones, 2001 p.197); as they understand the consequences of binge-eating regularly. The diagnostic criteria for Bulimia Nervosa stated by the DSM includes: recurrent binge eating episodes (a minimum of 2 episodes per week for a minimum of 3 months), a sense of a lack of control during binge eating and frequent engagement in self-induced vomiting (APA, 1987, p.68). Although binge eating is recognised as a behaviour of Bulimia sufferers; sufferers who solely binge-eat without purging are classified as suffering from Binge Eating Disorder. As stated by the NHS (ND) the predominant symptom of Binge Eating Disorder is weight gain, which can lead to serious health problems (to be discussed further on in this essay). Sufferers of Binge Eating Disorder and Bulimia commonly experience cravings for sugary foods, headaches and pain within the stomach (NHS, ND). Psychologically, Binge Eating Disorder and Bulimia Nervosa sufferers may appear to be anxious or depressed and often display signs of a sense of guilt after eating which in the case of Bulimia, results in purges.
It is important to recognise that exercise disorders often come hand in hand with other eating disorders such as Anorexia Nervosa or Bulimia Nervosa and although they will not be explored in great detail it is important to have an understanding of these disorders. Some symptoms of exercise disorders include: an increase in the amount of exercise carried out due to the belief that a gap in training will result in weight gain, compulsive setting of goals and targets, dissatisfaction after exercising and participating in exercise out of a need rather than for enjoyment.
Exercise Disorders, as an accompaniment of other eating disorders (Gavin, 2010) are thought to arise from an individual’s desire to gain control within their lives and as a coping strategy for difficult emotions such as depression or anger; it is thought that exercise provides a release for these emotions (Gavin, 2010). Many sufferers will go out of their way to find an excuse to be active, for example it is known that some sufferers use stairways which they ascend and descend in order to obsessively burn calories (Beumont, 2002, p.162).
In order to make a diagnosis of an eating disorder, an individual’s body mass index (BMI) is calculated and compared to a standard BMI chart (Abraham & Llewellyn-Jones, 2001, p.28) and the individual is assessed against a set of diagnostic criteria specific to the suspected eating disorder type. For women, if their BMI is calculated to be below 17.5 and 18.5 then the individual is declared as being underweight; however, if they display signs of the diagnostic criteria then it is probable that the individual is suffering from an eating disorder of some kind (Abraham & Llewellyn-Jones, 2001, p.28). Although BMI assessment is often effective, it is important to note that BMI charts fail to consider muscle weight or other individual differences such as age (Abraham & Llewellyn-Jones, 2001, p.28); therefore, the results of the BMI match may be misleading.
Previously eating disorders were thought to be the consequence of behavioural aspects such as the avoidance of food (Ogden, 2010, p211). However, it is now widely understood that these disorders often emerge as a coping strategy during times of emotional difficulty such as stress, anxiety, depression, anger and loneliness (Beat, 2010). This is thought to be because “physical pain is much easier to deal with than emotional pain” (Harvey, 2007). Sufferers obtain a sense of control during difficult times of their lives by using food as a way of coping with these difficult emotions (Ogden, 2010, p.212). However, by doing so, they suppress their issues, burying them deeper and in time, making them more difficult to face. Although eating disorders are now commonly recognised as coping strategies for psychological struggles, it is important to recognise that other factors can contribute to the onset of eating disorders. In some cases it is thought that social factors can trigger the arousal of body dissatisfaction which commonly leads to dieting and under-eating (Ogden, 2004, p.153). For example, the media will commonly use thin females and toned males in advertising which lulls members of society into a false belief that all members of society are thin or toned (Ogden, 2004, p.148). In turn, this causes people to feel self-conscious about their differences to these idealistic body types displayed across the media, therefore creating insecurities. The family is also thought to be a social factor influencing body dissatisfaction; in particular within mother and daughter relationships whereby mothers are dissatisfied with their own bodies and trigger similar feelings in the daughter concerning her own body (Ogden, 2004, p.150). Aside from these contributing factors, studies carried out in the form of personality questionnaires have shown that sufferers of Anorexia Nervosa and Bulimia Nervosa present signs of low self-esteem and depressive or obsessive personality types; often combined with neurotic tendencies (Abraham & Llewellyn-Jones, 2001, p.50). These personality traits result in unstable foundations of a person’s personality and are thought to contribute to causing the individual to be more susceptible to disorders. A study carried out in American, involving 300 students, has suggested that conformists are also more susceptible to eating disorders (UNSW, ND). The study involved the completion of questionnaires containing questions specifically designed to assess the student’s individual dietary tendencies, conformity levels and body-image related concerns (UNSW, ND). It was concluded that participants whose responses indicated a sense of isolation and rejection from social groups were more likely to conform (UNSW, ND) and therefore it could be suggested that they may be more likely to attempt to fit into the ‘norms’ surrounding them. This links back to the influence the media is thought to have upon the prevalence of eating disorders.
It is thought that significant life events such as childhood sexual abuse and parental loss can play a part in the cause of eating disorders, this is sometimes be down to a lack of, or poor quality of support given after a person experiences such events (Nauert, 2012). Studies have shown that approximately 30 percent of eating disorder sufferers had experienced childhood sexual abuse. Significant events such as these are thought to affect the individual’s ability to cope with difficult situations and issues during their adult life (Abraham & Llewellyn-Jones, 2001, pp.68 -69). This struggle to cope during adult life is thought to be due to the fact that unmanaged emotions and memories frequently resurface, triggered by sounds or particular situations (VictimSupport, ND). These life events are also thought to cause the victim to feel a loss of control (VictimSupport, ND) which some victims then regain through the control of their eating. Although studies have shown that approximately 30 percent of eating disorder sufferers had been abused during their childhood, as stated by Connors and Morse (1993) “Child sex abuse is neither necessary nor sufficient for the development of an eating disorder” (cited in Ogden, 2010, p.251). Therefore, childhood sexual abuse is not considered a cause but a potential risk factor for the development of an eating disorder (Ogden, 2010, p.251). While the Significant Events Theory has strength in the fact that it addresses past events experienced by the eating disorder sufferer, the theory fails to explain why many victims of childhood sexual abuse do not develop an eating disorder, nor can the theory explain the increase in the amount of eating disorders cases today (Ogden, 2010, p.252).
Through the discussion of potential causes of eating disorders the question arises as to whether such disorders are caused by nature or nurture? Evident from the causes discussed, although it can be suggested that different personality types can cause people to be susceptible to an eating disorder, it is also dependent on the environment in which the individual lives or has previous experience of. For example, it is unlikely that without the presence of other contributing factors such as the media’s portrayal of the ideal body or a significant life event that the individual will engage in disordered eating.
The effects of an eating disorder are specific to the individual and can come in a range of forms including psychological, biological, physical and social. Psychologically, sufferers of an eating disorder can sometimes develop symptoms indicating depression and anxiety; it is thought that sufferers are also at risk for self harm and in some cases, suicidal behaviour (McCallum, ND). This is evident in an article from The Guardian written by Louisa Harvey, a recovering eating disorder sufferer. Louisa claims that she suffered from depression as a result of her disorder and “thought about suicide daily” (Harvey, 2007). Depression, as a consequence of Anorexia Nervosa and other eating disorders, could potentially be caused by the underlying difficult emotions suppressed by the disorder. However, the anxiety and depression experienced by Bulimia Nervosa sufferers is thought to be caused by the guilt believed to be felt as a result of the eating binges. Although, as previously mentioned, depression is recognised as a possible cause of eating disorders it is in fact suggested that depression is more commonly seen as an effect of these disorders, rather than the cause (Abraham & Llewellyn-Jones, 2001, p.192). Similarities can be drawn between the effects of famine and Anorexia Nervosa in that starvation of any kind results in the brain shrinking. This is understood to be caused by dehydration and under-nutrition and is believed to cause changes in an individual’s personality (Abraham & Llewellyn-Jones, 2001, p.150). These personality changes may include increased irritability, low moods, perfectionism and obsessive-compulsive behaviours (Abraham & Llewellyn-Jones, 2001, p.150). Sufferers commonly find it hard to relax and become hyperactive; for some sufferers this results in the individual suffering from insomnia which, if prolonged, causes exhaustion. Poor consumption of food and nutrition are also thought to be the cause of the poor concentration evident in some eating disorder sufferers (Garner, 2002, p.143) which can affect their lives socially as well as mentally. Sufferers commonly display signs of social withdraw which is possibly as a result of social anxiety experienced by the sufferers (Garner, 2002, p.143). This withdrawal from social situations is likely to impact upon their relationships with other people such as friends and the sufferer may end up being excluded from such relationships. It is believed that many sufferers of eating disorders have an external locus of control. The locus of control concept refers to a person’s perception as to where the control of a situation comes from and was developed by Rotter in 1966 (Hayes, 1994, p.452). The concept claims that people with an external locus of control believe that they have little control over situations and believe that most situations are controlled by luck or fate.
Aside from the psychological and social consequences of eating disorders, there are also many physical and biological disturbances caused. Changes in a sufferer’s hormone levels is understood to have significant biological effects on the individual, in particular, a reduced heart rate; this is understood to be caused by the reduced functioning of the thyroid gland (Abraham & Llewellyn-Jones, 2001, p.150). Biological effects caused by Anorexia Nervosa include: gum disease, tooth decay, loss of periods and growth of fine hair over the body (GHFED, 2013). These effects are thought to be predominantly caused by malnutrition and the shutting down of body systems, which is done in order to preserve energy in Anorexia Nervosa sufferers. Biological effects specific to Bulimia Nervosa firstly include the fluctuation in weight, which is understood to be caused by eating binges and purging. Purges result in a range of biological effects such as damage to the oesophagus and rotting of the teeth caused by the stomach acids and burst blood vessels in the eyes and cheeks caused by the frequent purging. Other biological effects, which are specific to Bulimia Nervosa are internal bleeding and complications within the digestive system including ulcers and constipation (GHFED, 2013).
The effects of an eating disorder, although predominantly experienced by the sufferer, can also be evident amongst friends and family members of the sufferer. Firstly the family, in particular the parents, may feel a sense of confusion surrounding the reasons behind why their child has developed an eating disorder, especially if the sufferer is unwilling to talk about their disorder. Parents may also feel a sense of anger which may arise from being unable to comprehend the reasons why their child is harming their own body and for putting the family through the worry and stress which comes with an eating disorder. Guilt is thought to be a common emotion felt by the family of a sufferer and this is believed to come from the fact that they feel that they should have been aware of the disorder sooner (Thompson, 2011). Aside from the emotions felt by a sufferer’s family, it is possible that eating disorders have an impact on a family routine, in particular, meal times; this is because sufferers often withdraw themselves from meal times, making it especially difficult if there are other children in the family. Other siblings of a sufferer may feel neglected as a result of an eating disorder due to the fact that the sufferer will require more attention and special care; it is therefore important for the parents to recognise how the other children may feel and ensure that they are still given the attention that all children need.
It is believed that male eating disorder sufferers have been reported since 1689 (Andersen, 2002, p.189). However, throughout literature and the media, eating disorders amongst males are less widely recognised when compared to the recognition of female sufferers. Although studies show that eating disorders are less prevalent amongst men, it is still important that they receive recognition and a fair chance of diagnosis. Studies taken from within communities and clinics show a difference in the ratio of male to female sufferers with 1 males case to every 6 females cases recorded within a community study and a much smaller 10-20 percent of cases being male in clinic studies (Andersen, 2002, p.189). This difference suggests that males are less likely to approach the health services for help or an official diagnosis. This resistance to help could be due to the way men are portrayed in society through stereotypical assumptions such as men are able to cope with emotions. Because of this, many men may feel like they should be able to cope and may feel embarrassed to approach healthcare services for help.
In terms of diagnosis and treatment of male sufferers, Andersen (2002, p.189) states that gender has little influence upon diagnosis and the effectiveness of treatment. However, Lock (2009) argues that males are poorly accommodated in the prevention, diagnosis and treatment of eating disorders. Lock (2009) recognises that there is a lack of research into whether or not males and females respond differently to treatments and acknowledges that much of the criteria and the methods used for assessment and treatment of an eating disorder are based upon females and their body structure. A study carried out in The New York Hospital by Braun et al (1999) was predominantly carried out to compare the disorder diagnosis, age at admission, age at onset and duration of the eating disorder. Admissions of 51 males and 693 females were recorded between 1984 and 1987 and data from these cases showed that the onset of eating disorders within males commonly occurred at later stage when compared to females; approximately 21 years of age for males and 17 years of age for females (Braun et al, 1999). The results of the study also showed that many of the male sufferers were participants in sports where performance was influenced by body shape (Braun et al, 1999). The study also addressed the admission rates of males with eating disorders between 1984 and 1996 and the data showed a significant increase in male admissions from 0 percent 1984 to 11 percent of eating disorder cases being male in 1993 (Braun et al, 1999). It could be suggested that if the number of male eating disorder cases continues to rise, as suggested by Lock (2009), more research into the diagnosis and treatment of eating disorders amongst males should be carried out.
The type of and way in which treatment is delivered to a sufferer of an eating disorder will be specific to the individual and type of eating disorder. The general outcome desired through treatment of Anorexia Nervosa is weight gain, for Bulimia Nervosa the aim of treatment is to reduce the desire or need to binge-eat (MFMER, 2012b). Although there are a variety of psychological treatments including Cognitive Behavioural Therapy, Interpersonal Psychotherapy and Family Therapy it is understood that Cognitive Behavioural Therapy (CBT) is the most widely used treatment for eating disorders (Fairburn, 2002, p.308); commonly referred to as CBT-E (Enhanced CBT) in these cases. This type of therapy is popular as it is thought to be perfectly matched for treating these disorders, because CBT-E strives to implement cognitive change and eating disorders are believed to be disorders of cognitive functioning (Fairburn, 2008, p.23). CBT-E is also thought to be an appropriate therapy for eating disorders because it can easily be adapted to treat different eating disorder types (Fairburn, 2013). This adaptable quality is important as it is widely understood that eating disorder sufferers do not suffer from just one type, but instead shift between different behaviours associated with different eating disorders once they are “locked in to the thought cycle of eating disorders” (Fairburn, 2013). There are four stages of CBT-E and the frequency of treatment sessions declines throughout these stages (Fairburn, 2008, p.24). Stage one involves engaging and educating the client about the eating disorder in order to broaden their understanding in preparation for treatment and implementing regular eating patterns (Fairburn, 2002, p.305). It is during stage one that a formulation is created; this is based on the potential underlying processes causing the eating disorder, which allows the therapist to understand which areas need targeting through therapy (Fairburn, 2008, p.24). During stage two, the therapist and the client continually review the therapy and adapt to any new problems which may have become apparent; these are added into the formulation and addressed in following sessions (Fairburn, 2008, p.25). Stage three is where the main contributing factors to the eating disorder are addressed. These factors are often the barriers preventing the client from having already recovered and will be specific to the individual; this stage is thought to have the biggest impact within treatment (Fairburn, 2008, p.25). The final stage, four, is focused upon preparing the client for the end of treatment. During this stage the client and therapist work together to set manageable goals for maintaining the cognitive shift achieved and implementing a plan for dealing with potential setbacks in the client’s progress (Fairburn, 2002, p.305). There are many strengths of CBT-E including the fact that it can be adapted to treat a range of eating disorders and clients of different ages (Fairburn, 2008, p.23). Another strength of CBT-E is that its dropout rates are low, with just 15-20 percent dropout rates recorded in many healthcare centres (Fairburn, 2002, p.306). This suggests that it is a treatment which continually engages the client and it could also be suggested that the frequent review of sessions enables the therapist to understand the client’s specific need and adapt sessions to suit these; resulting in a potentially good relationship between the client and therapist. Another strength of CBT-E comes from the fact that in most cases it aims to address many aspects of an eating disorder (Fairburn, 2002, p.306), dealing with the causes of the disorder rather than just the symptoms, as drugs are commonly recognised for. This holistic approach to treatment provided by CBT-E supplies a more long term treatment in comparison to drug treatments but may not be suited to individuals who struggle to remain motivated and engaged with the therapy. The success rate of recovery is also high for CBT-E and as discussed by Fairburn (2013), this is shown through a study carried out in Copenhagen by Poulsen et al (Fairburn, 2013). This study showed that CBT-E had a 60 percent success rate which was reviewed and recorded for 24 months and sustained its success during this time (Fairburn, 2013).
Occupational therapy (OT) is a management strategy used with sufferers of eating disorders and is often used within eating disorder services. An occupational therapist usually works as part of a multidisciplinary team and aims to provide and encourage a balance between the eating disorder and other meaningful occupations such as socialising, hobbies or other interests in the daily life of sufferers (Clemmer, 2009). An occupational therapist will collaborate with a client in order to set realistic goals of the therapy to suit the individual’s needs. Following this, a treatment plan is then created which may involve planning meals and snacks, developing or learning new skills or arranging participation in a range of activities which interest the client. The fact that OT addresses all aspects of an individual and their surrounding environment and works with these, means that the therapy is very client focused and adaptable to meet individual requirements (COT, 2011); this potentially results in a more effective outcome when compared to more standardised and less personalised treatments.
To conclude, although eating disorders are often mentioned within the media, they are frequently unexplained and therefore misunderstood by many members of the public. Eating disorders come in a range of forms from Anorexia Nervosa, Bulimia Nervosa, binge eating, unspecified eating disorders and exercise disorders. Eating disorders are believed to commonly be triggered by an individual experiencing a situation or emotion which is difficult to deal with psychologically and t
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