- Psychiatry, Alcohol disorders, Substance Abuse, Alcohol Addiction, Drug Addiction, Gender, and 16 moreIdentity, Body Image, Eating Disorders, Domestic Violence, Subjectivities, Feminism, Critical Social Research, Qualitative Research, Women and Food/eating, Dieting, Psychotherapy, Counseling, Suicide, Kvalitativ Analys, Fenomenografi, and Psychologyedit
ABSTRACT There is a knowledge gap about predictors of treatment outcomes in alcohol use disorder (AUD) in socially stable women. This study examined factors that may predict abstinence 12 months after the end of treatment for AUD in... more
ABSTRACT There is a knowledge gap about predictors of treatment outcomes in alcohol use disorder (AUD) in socially stable women. This study examined factors that may predict abstinence 12 months after the end of treatment for AUD in socially stable women. Fifty-seven women with AUD participated in 12-month follow-up. Information about sociodemographic, alcohol-related, psychiatric symptoms, psychological functioning, and participants’ treatment goals and ability to change alcohol habits were gathered from structured interviews and self-report instruments. Predictors for abstinence at the 12-month follow up were calculated by univariable and multivariable logistic regression models. Significant predictors for abstinence were having no history of childhood abuse (OR: 8.13; 95%CI: 2.22–29.75; p < .01) and a goal of abstinence at the end of treatment (OR: 15.17; 95%CI: 3.45–66.69; p < .001). Most participants (>60%) achieved their goals of abstinence or low-risk drinking. The results highlight the significance of identifying patients with experiences of childhood abuse, since such experiences may adversely affect the outcome of AUD treatment. Our findings also emphasize the importance of patients’ own goals of abstinence, since it resulted in the most stable outcome. Treatment could, therefore, also focus on motivating individuals to aim for abstinence.
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Follow-up information about outcome for hospitalized mentally disordered offenders (MDO) is necessary for evaluation and improvement in quality of forensic psychiatric care. A study was undertaken to estimate the standard mortality rate... more
Follow-up information about outcome for hospitalized mentally disordered offenders (MDO) is necessary for evaluation and improvement in quality of forensic psychiatric care. A study was undertaken to estimate the standard mortality rate (SMR) of a population based sample of people sentenced to forensic psychiatric care. All MDOs in Orebro County, Sweden, discharged from a forensic psychiatric treatment unit between 1992 and 1999 were identified (n = 46). The variables were gender, age, offence, diagnosis and duration of admission. Case linkage was made with the National Cause-of-Death register. Median follow-up time was 53 months (0-93). The sample yielded a significantly elevated SMR 13.4 (95% CI 4.35-31.3) times higher than that in the general population, mostly due to suicide. The cohort size is small but representative, and it provides data from an additional country for the growing international pool confirming the high risk of premature, generally self-inflicted death among MDOs. Resettlement and rehabilitation services for them may need to take as much account of mortality risk as that of re-offending.
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Research Interests: Psychology, Cognitive Science, Interpersonal Communication, Eating Disorders, Adolescent, and 15 moreMedicine, Anorexia Nervosa, Bulimia Nervosa, Humans, Female, Body Mass Index, Patient Admission, Adult, Drop Out, Body Weight, Eating Disorder, Bulimia, Psychology Psychotherapy, Ambulatory Care, and Personality Inventory
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The impact of using different outcome measures on remission rates in a three-year follow-up of eating disorders
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ABSTRACT Psychiatric symptoms and personality characteristics were studied in men (n = 252) and women (n = 86) as they commenced treatment for excessive alcohol use. The Addiction Severity Index, Symptom Check List, and Temperament and... more
ABSTRACT Psychiatric symptoms and personality characteristics were studied in men (n = 252) and women (n = 86) as they commenced treatment for excessive alcohol use. The Addiction Severity Index, Symptom Check List, and Temperament and Character Inventory were used. ANOVA with early/late onset and gender as covariates showed significantly lower scores for psychiatric symptoms and more mature personality characteristics in the late-onset group compared to early onset. Men described more depression and anxiety, and women higher persistence. Results indicate the importance of considering age at onset of excessive alcohol use when patients enter treatment because different treatment approaches may be required.
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It is unclear whether exposure to childhood maltreatment is associated with the age of onset of alcohol use disorder (AUD). A group of socially stable women with AUD seeking treatment (n = 75) were interviewed using the Addiction Severity... more
It is unclear whether exposure to childhood maltreatment is associated with the age of onset of alcohol use disorder (AUD). A group of socially stable women with AUD seeking treatment (n = 75) were interviewed using the Addiction Severity Index and the Mini International Neuropsychiatric Interview. They also filled out the Childhood Trauma Questionnaire-short form. Emotional abuse, sexual abuse and multiple childhood traumas were found to be associated with earlier onset of AUD. Multivariable linear regression analysis showed that independent predictors for an earlier onset of AUD were exposure to emotional abuse (beta = –7.44, SE = 2.83, adjusted p = 0.010) and mother’s alcohol/substance problems (beta = –7.87, SE = 3.45, adjusted p = 0.026). These variables explained 18.9% of the variance of age of onset of AUD. These findings highlight a need for increased clinical attention to AUD subgroups who have experienced childhood maltreatment, especially emotional abuse, as well as a need for including support in the patient’s own parental role in the treatment.
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To examine the impact of using different outcome measures on estimates of remission rates in eating disorders (ED). Adult ED patients (n = 334) included in a naturalistic, longitudinal project were assessed 3 years after intake. Remission... more
To examine the impact of using different outcome measures on estimates of remission rates in eating disorders (ED). Adult ED patients (n = 334) included in a naturalistic, longitudinal project were assessed 3 years after intake. Remission was operationally defined using six different measures of outcome. Pairwise analyses of agreement between outcome measures were also calculated. Remission rates for the entire group varied considerably from 24.3 to 77.8% depending on how remission was defined and who made the assessment (experts or patients). Outcome measures performed differently depending on diagnosis, and agreement between measures varied from none to very good. The impact of different definitions of outcome on remission estimates is considerable. There is a need to validate different estimates of remission by examining them in relation to multiple domains of outcome over time and by critically examining their relative merits both empirically and clinically.
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The aim of this study was to describe how former male patients perceive life after recovery from an eating disorder. A qualitative method with a phenomenographic approach was used to identify ways of experiencing recovery. Two descriptive... more
The aim of this study was to describe how former male patients perceive life after recovery from an eating disorder. A qualitative method with a phenomenographic approach was used to identify ways of experiencing recovery. Two descriptive categories were developed: body acceptance and self-worth. Six conceptions describe how recovered patients now relate in a balanced way to exercise and food, using strategies to avoid relapse. With a sense of self-acceptance and autonomy, they now appreciate their social life. Some perceive recovery as coping with remaining impulses to diet or exercise. Others experience themselves as totally free from the eating disorder.
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Eating disorders or the use of anabolic androgenic steriodes in males : Different manifestation of negative self-image?
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The aim of this investigation was to define more clearly specific forensic-psychiatric characteristics of female murder or attempted murder perpetrators. The retrospective method applied was based on the comparison of the data from... more
The aim of this investigation was to define more clearly specific forensic-psychiatric characteristics of female murder or attempted murder perpetrators. The retrospective method applied was based on the comparison of the data from forensic-psychiatric assessments carried out in the Center for Forensic Psychiatry, Psychiatric Hospital Vrapee, Zagreb, from 1983 to 1997 (including 70 female and 70 male subjects who committed murder or attempted murder). Compared with men, female offenders were most often in some way emotionally related to their victims, and they were more often victimized themselves before committing the crime. ln men alcoholism was a more significant circumstantial factor in the assessment of their accountability. Psychiatric security measures were more often given to male offenders. The intensity of aggression was lower in females than in males. This investigation reveals that there are some sex specific forensic-psychiatric traits of murder or attempted murder perpetrators. The obtained results could be of help in everyday forensic-psychiatric practice, both in assessments and treatment. Background: Tbe crime rate among people with schizophrenia is known to exceed the crime rate in the general population. Objective: To analyse the temporal relationship between the first committed (violent and non-violent) crime and the first contact to the psychiatric hospital system and when the diagnosis of schizophrenia is ftrst given. Method: A register based study linking The National Crime Register and The Psychiatric Central Research Register. Results: A substantial part of especially the schizophrenic men commit their first crime before the f&t contact to the psychiatric hospital system. Conclusion: A higher degree of cooperation and coordiantion between the judicial and the psychiatric system is needed to assess these individuals properly.
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The Impact of Childhood Maltreatment on Onset Age of Alcohol Use Disorder in Women Seeking Treatment
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Our aim in this study was to describe how patients perceive having recovered from eating disorders. A qualitative method with a phenomenographic approach was used to identify various ways of experiencing recovery. Four categories emerged,... more
Our aim in this study was to describe how patients perceive having recovered from eating disorders. A qualitative method with a phenomenographic approach was used to identify various ways of experiencing recovery. Four categories emerged, describing how the subjects now relate in a relaxed and accepting manner to food, the body, themselves as individuals, and their social environment. Some perceived recovery as coping with emotions, while others experienced themselves as healthier than people in general regarding food and weight. Different aspects were emphasized as important for recovery. As long as patients perceive themselves as recovered, it is not necessary that they fulfill all conceivable criteria for recovery.
Research Interests: Psychology, Nursing, Perception, Eating Disorders, Quality of life, and 15 moreQualitative Research, Body Image, Risk assessment, Medicine, Humans, Female, Interpersonal Relations, Questionnaires, Adult, Prognosis, Body Weight, Eating Disorder, Risk Assessment, Qualitative Method, and Cohort Studies
The aim of this investigation was to define more clearly specific forensic-psychiatric characteristics of female murder or attempted murder perpetrators. The retrospective method applied was based on the comparison of the data from... more
The aim of this investigation was to define more clearly specific forensic-psychiatric characteristics of female murder or attempted murder perpetrators. The retrospective method applied was based on the comparison of the data from forensic-psychiatric assessments carried out in the Center for Forensic Psychiatry, Psychiatric Hospital Vrapee, Zagreb, from 1983 to 1997 (including 70 female and 70 male subjects who committed murder or attempted murder). Compared with men, female offenders were most often in some way emotionally related to their victims, and they were more often victimized themselves before committing the crime. ln men alcoholism was a more significant circumstantial factor in the assessment of their accountability. Psychiatric security measures were more often given to male offenders. The intensity of aggression was lower in females than in males. This investigation reveals that there are some sex specific forensic-psychiatric traits of murder or attempted murder perpetrators. The obtained results could be of help in everyday forensic-psychiatric practice, both in assessments and treatment. Background: Tbe crime rate among people with schizophrenia is known to exceed the crime rate in the general population. Objective: To analyse the temporal relationship between the first committed (violent and non-violent) crime and the first contact to the psychiatric hospital system and when the diagnosis of schizophrenia is ftrst given. Method: A register based study linking The National Crime Register and The Psychiatric Central Research Register. Results: A substantial part of especially the schizophrenic men commit their first crime before the f&t contact to the psychiatric hospital system. Conclusion: A higher degree of cooperation and coordiantion between the judicial and the psychiatric system is needed to assess these individuals properly.
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ABSTRACT A total of 54 patients treated in psychiatric observation and intensive in-patient care units completed the questionnaire Quality in Psychiatric Care – In-patient (QPC-IP). The patients rated the quality highest in the dimension... more
ABSTRACT A total of 54 patients treated in psychiatric observation and intensive in-patient care units completed the questionnaire Quality in Psychiatric Care – In-patient (QPC-IP). The patients rated the quality highest in the dimension Encounter and lowest in the dimension Discharge. Those patients who knew who their doctor was, or where to complain, having prescription of medication, being discharged to their own homes, having a planned contact after treatment or having a supportive talk, rated significantly higher quality of care. Demographic factors were shown to have had only a minor impact on quality of care. Using the QPC-IP gave valuable information about patient&#39;s perceptions of quality of care and identified areas important to improve.
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Objective Previous literature has suggested that identifying putative differences in health care seeking patterns before death by suicide depending on age and gender may facilitate more targeted suicide preventive approaches. The aim of... more
Objective Previous literature has suggested that identifying putative differences in health care seeking patterns before death by suicide depending on age and gender may facilitate more targeted suicide preventive approaches. The aim of this study is to map health care utilisation among individuals in the two years prior to suicide in Sweden in 2015 and to examine possible age and gender differences. Methods Design: A retrospective explorative study with a medical record review covering the two years preceding suicide. Setting: All health care units located in 20 of Sweden’s 21 regions. Participants: All individuals residing in participating regions who died by suicide during 2015 (n = 949). Results Almost 74% were in contact with a health care provider during the 3 months prior to suicide, and 60% within 4 weeks. Overall health care utilisation during the last month of life did not differ between age groups. However, a higher proportion of younger individuals (< 65 years) were i...
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Additional file 1.. An overview of benzodiazepine prescriptions. Data obtained from a two-sample chi-square test for categorical variables (df = 1), comparing cases and controls regarding benzodiazepine prescriptions. (DOCX 23 kb)
ABSTRACT There is a knowledge gap about predictors of treatment outcomes in alcohol use disorder (AUD) in socially stable women. This study examined factors that may predict abstinence 12 months after the end of treatment for AUD in... more
ABSTRACT There is a knowledge gap about predictors of treatment outcomes in alcohol use disorder (AUD) in socially stable women. This study examined factors that may predict abstinence 12 months after the end of treatment for AUD in socially stable women. Fifty-seven women with AUD participated in 12-month follow-up. Information about sociodemographic, alcohol-related, psychiatric symptoms, psychological functioning, and participants’ treatment goals and ability to change alcohol habits were gathered from structured interviews and self-report instruments. Predictors for abstinence at the 12-month follow up were calculated by univariable and multivariable logistic regression models. Significant predictors for abstinence were having no history of childhood abuse (OR: 8.13; 95%CI: 2.22–29.75; p < .01) and a goal of abstinence at the end of treatment (OR: 15.17; 95%CI: 3.45–66.69; p < .001). Most participants (>60%) achieved their goals of abstinence or low-risk drinking. The results highlight the significance of identifying patients with experiences of childhood abuse, since such experiences may adversely affect the outcome of AUD treatment. Our findings also emphasize the importance of patients’ own goals of abstinence, since it resulted in the most stable outcome. Treatment could, therefore, also focus on motivating individuals to aim for abstinence.
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Eating disorders or the use of anabolic androgenic steriodes in males : Different manifestation of negative self-image?
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INTRODUCTION The aim was to investigate psychiatric health care utilization two years before death by suicide among individuals with previous suicide attempts (PSA) compared with those without (NSA). METHOD A retrospective... more
INTRODUCTION The aim was to investigate psychiatric health care utilization two years before death by suicide among individuals with previous suicide attempts (PSA) compared with those without (NSA). METHOD A retrospective population-based cohort study was conducted including 484 individuals who died by suicide in Sweden in 2015 and were in contact with psychiatric services within the two years preceding death, identified through the Cause of Death register. Data on psychiatric health care two years before death, including suicide attempts according to notes in the medical record was used. Associations between having at least one PSA vs. NSA and health care utilization were estimated as odds ratios (OR) with 95% confidence intervals (CI) by logistic regression analyses. RESULTS Of the 484 individuals included, 51% had PSA. Those with PSA were more likely than NSA to have received a psychiatric diagnosis [OR 1.96 (CI 95% 1.17-3.30)], to have ongoing psychotropic medication [OR 1.96 (CI 95% 1.15-3.36)] and to have been absent from appointments during the last three months [1.97 (1.25-3.13)]. In addition, elevated suicide risk was more often noted in the psychiatric case records of those with a PSA than those without [OR 2.17 (CI 95% 1.24-3.79)]. CONCLUSION The results underline the importance of improved suicide risk assessment as well as thorough diagnostic assessment and when indicated, psychiatric treatment as suicide preventive interventions regardless of PSA. Furthermore, the larger proportion of absence from appointments in individuals with PSA may indicate a need of improved alliance between psychiatric care providers and individuals with PSA.HIGHLIGHTSBeing assessed with elevated suicide risk was more common among those with previous attempt/s (PSA).One-fifth of all with no previous attempt (NSA) had no psychiatric diagnosis, compared to one in ten in those with PSA.Receiving psychotropic medication was more common among those with PSA.
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BackgroundResearch is required to identify those psychiatric interventions with a protective effect against suicide. The overarching aim of the current study was to examine whether completed suicide in psychiatric patients in a Swedish... more
BackgroundResearch is required to identify those psychiatric interventions with a protective effect against suicide. The overarching aim of the current study was to examine whether completed suicide in psychiatric patients in a Swedish population was associated with the quantity and nature of previous medical and psychosocial treatment interventions.MethodsThis retrospective case-control study (n = 308) compared a group of deceased psychiatric patients with matched controls. For every case of suicide, a control was found within psychiatry that matched according to sex, age, and primary psychiatric diagnosis. A stepwise forward logistic regression model with suicide as the dependent outcome variable was used.ResultsReceiving pharmacotherapy combined with psychotherapy [OR: 0.44 (95% CI: 0.226–0.876),p = 0.019] and a higher number of outpatient visits in psychiatry [OR: 0.99 (95% CI: 0.982–0.999),p = 0.028] were negatively associated with suicide. These associations were still signifi...
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Background To examine the relationship between treatment outcome, as measured according to change in alcohol consumption, and a history of childhood abuse (emotional, physical, sexual) in socially stable women undergoing treatment for... more
Background To examine the relationship between treatment outcome, as measured according to change in alcohol consumption, and a history of childhood abuse (emotional, physical, sexual) in socially stable women undergoing treatment for alcohol use disorder (AUD). Methods Participants were assessed using the Addiction Severity Index and the Mini International Neuropsychiatric Interview at the beginning of treatment (n = 75), end of treatment (n = 59) and 12 month follow-up after treatment (n = 57). Self-report data on alcohol consumption were obtained at all three time-points using the Alcohol Habits Inventory-Revised 2. Self-report data on childhood maltreatment were obtained at the beginning of treatment using the Childhood Trauma Questionnaire-short form. Study outcomes were changes in alcohol consumption (grams of pure alcohol per week), risk-drinking and reported abstinence. Results Of the 75 women enrolled, 38 (50.7%) reported a history of childhood abuse and the rest did not. B...
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Background It is unclear whether benzodiazepines increase the risk of suicide. The aim of this study was to test the hypothesis that benzodiazepines are associated with an increased risk of suicide, by comparing psychopharmacological... more
Background It is unclear whether benzodiazepines increase the risk of suicide. The aim of this study was to test the hypothesis that benzodiazepines are associated with an increased risk of suicide, by comparing psychopharmacological interventions between psychiatric patients who committed suicide and a group of matched controls. Methods The case group comprised 154 psychiatric patients (101 men, 53 women; age range: 13–96 years) who had committed suicide in Örebro County, Sweden. Control psychiatric patients matched by age, sex, and main psychiatric diagnosis were selected for each case. Binary logistic regression was used to calculate odds ratios in unadjusted and adjusted models. Results Benzodiazepine prescriptions were more common among cases than controls (65/154 [42.2%] versus 43/154 [27.9%], p = 0.009, odds ratio: 1.89 [95% CI: 1.17–3.03]). This association remained significant in a model adjusted for previous suicide attempts and somatic hospitalizations (odds ratio: 1.83 [...
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It is unclear whether exposure to childhood maltreatment is associated with the age of onset of alcohol use disorder (AUD). A group of socially stable women with AUD seeking treatment (n = 75) were interviewed using the Addiction Severity... more
It is unclear whether exposure to childhood maltreatment is associated with the age of onset of alcohol use disorder (AUD). A group of socially stable women with AUD seeking treatment (n = 75) were interviewed using the Addiction Severity Index and the Mini International Neuropsychiatric Interview. They also filled out the Childhood Trauma Questionnaire-short form. Emotional abuse, sexual abuse and multiple childhood traumas were found to be associated with earlier onset of AUD. Multivariable linear regression analysis showed that independent predictors for an earlier onset of AUD were exposure to emotional abuse (beta = –7.44, SE = 2.83, adjusted p = 0.010) and mother’s alcohol/substance problems (beta = –7.87, SE = 3.45, adjusted p = 0.026). These variables explained 18.9% of the variance of age of onset of AUD. These findings highlight a need for increased clinical attention to AUD subgroups who have experienced childhood maltreatment, especially emotional abuse, as well as a nee...
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IntroductionThere is a need of identifying predictors of suicide. With effective treatment interventions for those at highest risk, suicide can be prevented.AimTo investigate variables possibly associated with suicide, by comparing... more
IntroductionThere is a need of identifying predictors of suicide. With effective treatment interventions for those at highest risk, suicide can be prevented.AimTo investigate variables possibly associated with suicide, by comparing patients in psychiatry deceased by suicide to matched controls. We compared the psychiatric ward consumption two years prior to suicide, previous medical and psychological treatments, somatic co-morbidity and the professions of health care staff in previous visits.MethodThe 153 suicide cases, 101 (66%) men and 52 (34%) women, aged between 13 and 96 years, were identified from the National Cause of death registry. All cases had previous contact in psychiatry in Örebro County and died between January 1st 2007 through December 31st 2013. Each case had one gender-, age- and diagnosis matched patient control from psychiatry. Data on care usage were collected from medical records. Correlations were calculated between ward variables and the outcome variable suic...
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The impact of using different outcome measures on remission rates in a three-year follow-up of eating disorders
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Lack of participation in follow-ups is thought to be a serious bias in outcome research on eating disorders; however, little systematic knowledge exists about the problem. The present study aimed to delineate non-participation in... more
Lack of participation in follow-ups is thought to be a serious bias in outcome research on eating disorders; however, little systematic knowledge exists about the problem. The present study aimed to delineate non-participation in long-term follow-up research, and explore the reasons for non-participation. Eating disorder patients (N=840) entering a naturalistic, longitudinal multi-centre study were divided into participators (N=508) and non-participators (N=332) in 36-month follow-ups. Non-participators were further classified as either active (i.e. refused participation or failed to attend scheduled appointments) or passive non-participators (i.e. could not be traced). Active non-participators exhibited significantly lower levels of general and eating disorder psychopathology at intake compared to participators, while passive non-participators reported higher levels of hostility. Systematic exploration of non-participation in longitudinal research can help to mitigate the problem of indistinct results due to missing data. Barriers to successful longitudinal research and how to overcome non-participation at endpoint are discussed.
Research Interests: Clinical Psychology, Eating Disorders, Medicine, Comorbidity, Marriage, and 15 moreHumans, Female, Male, Mental Disorders, Body Mass Index, Clinical Sciences, Middle Aged, Longitudinal Studies, Adult, Analysis of Variance, Longitudinal Study, Hostility, Patient Participation, Occupations, and Age of Onset
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One of the goals in forensic psychiatric care is to reduce the risk of recidivism, but current knowledge about the general outcome of forensic psychiatric treatment is limited. To analyse the rate of criminal recidivism and mortality... more
One of the goals in forensic psychiatric care is to reduce the risk of recidivism, but current knowledge about the general outcome of forensic psychiatric treatment is limited. To analyse the rate of criminal recidivism and mortality after discharge in a sample of patients sentenced to forensic psychiatric treatment in a Swedish county. All offenders in Örebro County, Sweden, sentenced to forensic psychiatric treatment and discharged during 1992-2007 were included: 80 males and eight females. Follow-up data was retrieved from the Swedish National Council for Crime Prevention, the National Cause-of-Death register and clinical files. Mean follow-up time was 9.4 years. The mean age at discharge was 40 years. Schizophrenia, other psychoses and personality disorders were the most prevalent diagnoses. Thirty-eight percent of those still alive and still living in the country re-offended and were sentenced to a new period of forensic psychiatric treatment or incarceration during follow-up. Four male re-offenders committed serious violent crimes. Substance-related diagnosis was significantly associated with risk of recidivism and after adjustment for diagnoses, age and history of serious violent crime, the Hazard Ratio was 4.04 (95% CI 1.51-10.86, P = 0.006). Of all included patients, 23% had died at the end of follow-up (standardized mortality rate 10.4). Since repetition of serious violent crimes was unusual, results indicate a positive development subsequent to treatment for those alive at follow-up. The high mortality rate suggests that more attention should be paid in evaluation of the patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; somatic and psychiatric health during and after care in order to prevent premature death.
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The aim of this study was to describe how former male patients perceive life after recovery from an eating disorder. A qualitative method with a phenomenographic approach was used to identify ways of experiencing recovery. Two descriptive... more
The aim of this study was to describe how former male patients perceive life after recovery from an eating disorder. A qualitative method with a phenomenographic approach was used to identify ways of experiencing recovery. Two descriptive categories were developed: body acceptance and self-worth. Six conceptions describe how recovered patients now relate in a balanced way to exercise and food, using strategies to avoid relapse. With a sense of self-acceptance and autonomy, they now appreciate their social life. Some perceive recovery as coping with remaining impulses to diet or exercise. Others experience themselves as totally free from the eating disorder.