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Inadequate Engineers generic ranitidine 300mg overnight delivery gastritis diet óëûáêà, American Institute of Architects buy discount ranitidine 150 mg helicobacter gastritis diet, Illuminating Engineering artifcial lighting has been linked to cheap ranitidine 150 mg visa gastritis in pregnancy eyestrain discount 150mg ranitidine mastercard gastritis diet zaiqa, headache, and Society of North America, U. Explaining relationships among student experiences of sight, sound, and smell, which may serve as outcomes and the school’s physical environment. Halogen lamps and stairwells enables safe passage to emergency exits burn at a temperature of approximately 1200°F and are a or shelter-in-place locations in the event of an electrical potential burn or fre hazard (1). Open fames such as candles, fares, and more energy-effcient alternative to illuminate a room. Some portable lamps have eration should be given to providing emergency lighting a design that places the halogen bulb on the top of a tall in each room that is accessible to children. Although the base of these lamps is relatively heavy in homes, battery-powered household emergency lights that weight, children can easily tip the lamps on their side and insert into electrical wall outlets (to remain charged) may be cause a potential fre hazard. The fxtures are usually placed out of the reach of table emergency lighting in child care facilities. In some children and, if properly installed, should not pose a safety jurisdictions, fxed mounted emergency lighting may be hazard. These measures include ful when the outer bulb envelope is broken, causing serious noncombustible acoustical ceiling, rugs, wall covering, partiskin burns and eye infammation (1). This level Family Child Care Home of hearing loss correlates with decreased understanding of language. Mercury in the environment: A Research on the effects of ambient noise levels in child care danger to children. Although Emergency lighting approved by the local authority should noise sources may be located outside the child care facility, be provided in corridors, stairwells, and at building exits. High ceiling heights may these types of outlets look like standard wall outlets but contribute to noise levels. Installing acoustical tile ceilings contain an internal shutter mechanism that prevents children reduce noise levels as well as curtains or other soft window from sticking objects like hairpins, keys, and paperclips into treatments over windows and wall-mounted cork boards (4). This spring-loaded shutter mechanism While carpets can help reduce the level of noise, they can only opens when equal pressure is applied to both shutters absorb moisture and serve as a place for microorganisms such as when an electrical plug is inserted (2,3). Area rugs should be considered instead of carpet In existing child care facilities that do not have “tamperbecause they can be taken up and washed often. Area rugs resistant electrical outlets,” outlets should have “safety should be secured with a non-slip mat or other method to covers” that are attached to the electrical outlet by a screw prevent tripping hazards. For further assistance on fndcessible to children should use “tamper-resistant electrical ing an acoustical engineer, contact the Acoustical Society of outlets. Design of child care centers and curely attached safety covers prevent children from placing effects of noise on young children. Child Youth Care Forum tion when an electric outlet or electric product may come 30:55-64. Outlets and fxtures should be installed and connected to the source Plastic safety plugs inserted into electric outlets are not the of electric energy in a manner that meets the National Elecsafest option since they can easily be removed by children trical Code, as amended by local electrical codes (if any), and, depending on their size, present a potential choking and as certifed by an electrical code inspector. National electrical code fact ever, when used, they should bear the listing mark of a sheet: Tamper-resistant electrical receptacles. Injuries have ocDevices Near Water curred in child care when children pulled appliances such as tape players down on themselves by pulling on the cord (2). No electrical device or apparatus accessible to children When children chew on an appliance cord, they can reach should be located so it could be plugged into an electrical the wires and suffer severe disfguring mouth injuries (3). The fre extinguisher should be of that receive their operating power from the building electrithe A-B-C type. Size/number of fre extinguishers should be cal system or are of the wireless signal-monitored-alarm determined after a survey by the fre marshal or by an insursystem type should be installed. Instrucalarms should be permitted provided that the facility demtions for the use of the fre extinguisher should be posted onstrates to the fre inspector that testing, maintenance, and on or near the fre extinguisher. Fire extinguishers should battery replacement programs ensure reliability of power to not be accessible to children. Fire extinguishers should be the smoke alarms and signaling of a monitored alarm when inspected and maintained annually or more frequently as the battery is low and that retroftting the facility to connect recommended by the manufacturer’s instructions. A red slash through any of the symbols tells you the the building electrical system should keep a supply of batextinguisher cannot be used on that class of fre. Class A teries and battery-operated detectors for use during power designates ordinary combustibles such as wood, cloth, and outages. Wireless smoke alarm systems that signal and set off a monitored alarm are acceptable. However, for all new building installations Fighting a fre is secondary to the safe exit of the children where access to enable necessary wiring is available, and staff. For further informaauthority, to provide an adequate water supply to every tion, contact the local health authority or the U. Copper exposure can cause stomach and household well, programs should test the water every year intestinal distress, liver or kidney damage, and complicaor as required by the local health department, for bacteriotions of Wilson’s disease. Children’s bodies absorb more logical quality, nitrates, total dissolved solids, pH levels, and lead and copper than the average adult because of their other water quality indicators as required by the local health rapid development (2,3). Testing for nitrate is especially important if It is especially important to test and have safe water at child there are infants under six months of age in care. If a child care facility does Caregivers/teachers should always run cold water for ffteen not receive drinking water from a public water system, the to thirty seconds before using for drinking, cooking, and child care operator should ensure that the drinking water is making infant formula (3).

Gender-Related Diagnostic issues Females with dissociative identity disorder predominate in adult clinical settings but not in child clinical settings discount ranitidine 150mg gastritis diet jump. Adult males with dissociative identity disorder may deny their symptoms and trauma histories effective ranitidine 300mg gastritis chronic fatigue, and this can lead to purchase 150 mg ranitidine gastritis diet ãóãúë elevated rates of false negative di­ agnosis cheap ranitidine 150mg free shipping gastritis or ibs. Females with dissociative identity disorder present more frequently with acute dissociative states. Males commonly exhibit more criminal or vi­ olent behavior than females; among males, common triggers of acute dissociative states in­ clude combat, prison conditions, and physical or sexual assaults. Suicide Risk Over 70% of outpatients with dissociative identity disorder have attempted suicide; mul­ tiple attempts are common, and other self-injurious behavior is frequent. Assessment of suicide risk may be complicated when there is amnesia for past suicidal behavior or when the presenting identity does not feel suicidal and is unaware that other dissociated iden­ tities do. Functional Consequences of Dissociative identity Disorder Impairment varies widely, from apparently minimal. Regardless of level of disability, individuals with dissociative identity disorder commonly minimize the impact of their dissociative and posttraumatic symp­ toms. The symptoms of higher-functioning individuals may impair their relational, mar­ ital, family, and parenting functions more than their occupational and professional life (although the latter also may be affected). With appropriate treatment, many impaired in­ dividuals show marked improvement in occupational and personal functioning. These individuals may only respond to treatment very slowly, with gradual reduction in or improved tolerance of their dissociative and posttraumatic symptoms. The core of dissociative identity disorder is the division of identity, v^ith recurrent disruption of conscious functioning and sense of self. This central feature is shared with one form of other specified dissociative disorder, which may be distinguished from dissociative identity disorder by the presence of chronic or re­ current mixed dissociative symptoms that do not meet Criterion A for dissociative identity disorder or are not accompanied by recurrent amnesia. Individuals with dissociative identity disorder are often de­ pressed, and their symptoms may appear to meet the criteria for a major depressive episode. Rigorous assessment indicates that this depression in some cases does not meet full criteria for major depressive disorder. Other specified depressive disorder in individuals with dissocia­ tive identity disorder often has an important feature: the depressed mood and cognitionsfluc­ tuate because they are experienced in some identity states but not others. The relatively rapid shifts in mood in individuals with this disorder—typically within minutes or hours, in contrast to the slower mood changes typically seen in individuals with bipolar disorders—are due to the rapid, subjective shifts in mood commonly reported across dissociative states, some­ times accompanied by fluctuation in levels of activation. Furthermore, in dissociative identity disorder, elevated or depressed mood may be displayed in conjunction with overt identities, so one or the other mood may predominate for a relatively long period of time (often for days) or may shift within minutes. Dissociative identity disorder may be confused with schizophre­ nia or other psychotic disorders. The personified, internally communicative inner voices of dissociative identity disorder, especially of a child. Dissociative experiences of identity fragmentation or possession, and of perceived loss of control over thoughts, feelings, impulses, and acts, may be confused with signs of formal thought disorder, such as thought insertion or withdrawal. Individuals with dissociative identity disorder may also report visual, tactile, olfactory, gustatory, and somatic halluci­ nations, which are usually related to posttraumatic and dissociative factors, such as partial flashbacks. Individuals with dissociative identity disorder experience these symptoms as caused by alternate identities, do not have delusional explanations for the phenomena, and often describe the symptoms in a personified way. Persecutory and derogatory internal voices in dissociative identity disorder associated with depressive symptoms may be misdiagnosed as major depression with psychotic features. Chaotic identity change and acute intrusions that disrupt thought processes may be distinguished from brief psychotic disorder by the predominance of dis­ sociative symptoms and amnesia for the episode, and diagnostic evaluation after cessation of the crisis can help confirm the diagnosis. Symptoms associated with the physiological effects of a substance can be distinguished from dissociative identity disorder if the sub­ stance in question is judged to be etiologically related to the disturbance. Individuals with dissociative identity disorder often present identi­ ties that appear to encapsulate a variety of severe personality disorder features, suggesting a differential diagnosis of personality disorder, especially of tiie borderline type. This disorder may be distinguished from dissociative identity disorder by the absence of an identity disruption characterized by two or more distinct personality states or an experience of possession. Individuals with dissociative identity disorder may present with sei­ zurelike symptoms and behaviors that resemble complex partial seizures with temporal lobe foci. These include deja vu, jamais vu, depersonalization, derealization, out-of-body experiences, amnesia, disruptions of consciousness, hallucinations, and other intrusion phenomena of sensation, affect, and thought. Normal electroencephalographic findings, including telemetry, differentiate non-epileptic seizures from the seizurelike symptoms of dissociative identity disorder. Also, individuals with dissociative identity disorder obtain very high dissociation scores, whereas individuals with complex partial seizures do not. Individuals who feign dissociative identity disor­ der do not report the subtle symptoms of intrusion characteristic of the disorder; instead they tend to overreport well-publicized symptoms of the disorder, such as dissociative amnesia, while underreporting less-publicized comorbid symptoms, such as depression. Individuals who feign dissociative identity disorder tend to be relatively undisturbed by or may even seem to enjoy "having" the disorder. In contrast, individuals with genuine dissociative identity disorder tend to be ashamed of and overwhelmed by their symptoms and to underreport their symptoms or deny their condition. Sequential observation, cor­ roborating history, and intensive psychometric and psychological assessment may be helpful in assessment. Individuals who malinger dissociative identity disorder usually create limited, stereo­ typed alternate identities, with feigned amnesia, related to the events for which gain is sought. For example, they may present an "all-good" identity and an "all-bad" identity in hopes of gaining exculpation for a crime. Comorbidity Many individuals with dissociative identity disorder present with a comorbid disorder. If not assessed and treated specifically for the dissociative disorder, these individuals often receive prolonged treatment for the comorbid diagnosis only, with limited overall treat­ ment response and resultant demoralization, and disability. Individuals with dissociative identity disorder usually exhibit a large number of comorbid disorders. Other disorders that are highly comorbid with dissociative identity disorder include depressive disorders, traumaand stressor-related disorders, personality disorders (especially avoidant and borderline per­ sonality disorders), conversion disorder (functional neurological symptom disorder), somatic symptom disorder, eating disorders, substance-related disorders, obsessivecompulsive disorder, and sleep disorders.

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Transient episodes of hemiplegia purchase 300 mg ranitidine free shipping gastritis diet 7 hari, not related to buy 300 mg ranitidine free shipping diffuse gastritis definition clincaused by somatic mutation ranitidine 300mg without a prescription chronic gastritis no h pylori. Bilateral hemispheric involvement usually shows subtle or no abnormalities in young infants who are order ranitidine 300 mg without a prescription gastritis quiz, at a later increased severity of mental retardation (41). Onset of epilepsy before 2 years of age increases the risk of mental retardation and refractory epilepsy. The size of vention or secondary prevention (after first stroke-like cutaneous angioma does not predict the size of intracranial episode), but its efficacy is controversial, and there have been angioma. Usually it is in the V1 distribuprophylactic aspirin were found to have 65% fewer strokes tion with variable V2 and V3 involvement. Medical and surgical treatfound on the nape of neck above or below the hairline, upper ment of glaucoma includes beta-blockers, carbonic anhydrase trunk, or even the extremities, and hence may escape recogniophthalmic drops, and surgery. Even when facial angiomas are visual loss by aggressive glaucoma management has important bilateral, intracranial involvement tends to be unilateral or implications for future epilepsy surgery that likely involves dominant (asymmetric) on one side (21,41). Presence of vascular malformation in the distribution of V1 segment increases the probability of glaucoma. There may be associated vascular abnormality in the conjuctiva, sclera, retina, and choroid. There is reported spontaneous remission or controlled epilepsy in nearly increased incidence of retinal detachment secondary to hemorhalf (40). In medically refractory patients, presurgical evaluation rhages from the choroidal hemangiomas. The timing that may not be readily apparent in a young infant without an of surgery is important. The prognosis for cephaly or macrocephaly, hemimegalencephaly, infantile intellectual outcome is better in patients who underwent surgery spasms with hypsarrhythmia or hemihypsarrhythmia, and earlier (preferably before the age of 3 years) compared with other seizure types such as myoclonic, complex partial, partial those who were operated on later (37,46–50). Seizures are usually daily, catastrophic and fail to respond to medical treatment. Somatic ents is critical as the long-term outlook for neurocognitive mutation is postulated as the underlying genetic mechanism. Cutaneous lesions cal dysplasia, gyral fusion, pial glioneuronal hamartomas, cormay be subtle to detect due to their skin-like color and velvety tical astrocytosis, and foci of microcalcification. The cutaneous lesions may differ somewhat 5% of individuals, a rate that is slightly higher than in the genin histology. Some investigators prefer ety of seizure types, including infantile spasms, absence, generto group the cutaneous lesions together, whereas others mainalized convulsions, and complex partial seizures, have been tain that these are separate entities on the basis of histologic reported (60–63). The potential for malignant transformation cortical malformations, and mesial temporal sclerosis. Age of presentation varied from ter, we use the term epidermal nevus syndrome to encompass 4 days to over 20 years. Besides cutaneous manifestations, there is a wide spectrum of clinical presentation involving multiple organs and systems. Children with this disorder may Chapter 31: Epilepsy in the Setting of Neurocutaneous Syndromes 381 develop seizures (13. Sirolimus for angiomyolipoma in tuberous sclerosis complex or lymphangioleiomyomatosis. Efficacy of sirolimus in treating tuberous sclerosis and lymphangioleiomyomatosis. Morbidity associated with tuberous scleSeizures and mental retardation are also seen in approxirosis: A population study. I: Seizures, pertussis which irregular, hypopigmented skin lesions along the embryimmunisation and handicap. The tuberous sclerosis syndrome: Clinical onal lines of dermatologic fusion are seen. Autopsy showed magnetic resonance imaging and electroencephalography in 34 children gray matter heterotopias and abnormal cortical lamination in with tuberous sclerosis. Tuberous sclerosis: Long-term follow-up and longia patient in one series indicative of abnormalities in neuronal tudinal electroencephalographic study. Learning disability and epilepsy in an epidemiological sample of individuals with tuberous sclerosis complex. Magnetic resonance imaging in neurocutaneous syntypically measures greater than 5 cm. Subependymal giant cell tumors in tuberous patients usually present with seizures or increased intracranial sclerosis complex. The treatment of west syndrome: A patients are T1 shortening (increased signal) in temporal lobe cochrane review of the literature to December 2000. Usually there is leppatients with tuberous sclerosis and localization-related epilepsy. Incidence and prevalence of dren with tuberous sclerosis complex evaluated with alpha-[11C]methyl-Ltuberous sclerosis in Rochester, Minnesota, 1950 through 1982. Linear nevus sebaceous syndrome assoSturge–Weber syndrome and early onset seizures. Epilepsy surgery in epicorrelates with clinical severity in unilateral Sturge–Weber syndrome. Malformations of cortical and function in Sturge–Weber syndrome: Evidence of neurologic and radidevelopment in neurofibromatosis type 1. Hypomelanosis of ito: Spectrum of the epilepsy in Sturge–Weber syndrome in children. Outcomes of 32 hemispherectomies for melanocytic nevi and the risk for development of malignant melanoma and Sturge–Weber syndrome worldwide. Neurocutaneous melanosis: Definition and intractable seizures in the pediatric age group. In other instances, metabolic and for the clinician is to recognize these important diagnoses in mitochondrial diseases can masquerade as forms of cryptothe patient with epilepsy so that optimal medical treatment, genic epilepsy.

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Long-term effects of Hurricane Katrina on the psychological well-being of evacuees discount 150mg ranitidine with visa chronic gastritis surgery. Fluoxetine in the acute treatment and relapse prevention of combat-related post-traumatic stress disorder: analysis of the veteran group of a placebo-controlled order 300mg ranitidine visa chronic gastritis remedies, randomized clinical trial purchase 300 mg ranitidine otc biliary gastritis diet. The Transformation of Post-Traumatic Stress Disorder: From Neurosis to order ranitidine 150mg on-line gastritis diet list of foods to avoid Neurobiology 185 McFarlane, A. Cortisol and post-traumatic stress disorder in adults: systematic review and meta-analysis. Thickness of ventromedial prefrontal cortex in humans is correlated with extinction memory. Recall of fear extinction in humans activates the ventromedial prefrontal cortex and hippocampus in concert. Reducing Risk for Mental Disorders: Frontiers for Preventative Intervention Research, National Academies Press, Washington, D. The Management of Post Traumatic Stress Disorder in Primary and Secondary Care, National Institute for Clinical Excellence, London, U. No improvement of posttraumatic stress disorder symptoms with guanfacine treatment. Posttraumatic stress disorder in substance abuse patients: Relationship to 1-year posttreatment outcomes. Stress-induced norepinephrine release in the hypothalamic paraventricular nucleus and 186 Anxiety and Related Disorders pituitary-adrenocortical and sympathoadrenal activity: in vivo microdialysis studies. Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Prospective prediction of posttraumatic stress disorder symptoms using fear potentiated auditory startle responses. Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review. When not enough is too much: the role of insufficient glucocorticoid signaling in the pathophysiology of stress-related disorders. A parallel group placebo controlled study of prazosin for trauma nightmares and sleep disturbance in combat veterans with posttraumatic stress disorder. Neurocircuitry models of posttraumatic stress disorder and extinction: human neuroimaging research – past, present, and future. In: Trauma and Substance Abuse: Causes, Consequences, and Treatment of Comorbidity, P. Substance abuse and posttraumatic stress disorders: Symptom interplay and effects on outcome. The Transformation of Post-Traumatic Stress Disorder: From Neurosis to Neurobiology 187 Resick, P. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims, Journal of Consulting and Clinical Psychology, Vol. Cognitive enhancers as adjuncts to psychotherapy: Use of D-cycloserine in phobics to facilitate extinction of fear, Archives of General Psychiatry, Vol. Virtual reality exposure therapy for combatrelated posttraumatic stress disorder. A controlled study of eye movement desensitization and reprocessing in the treatment of post-traumatic stress disordered sexual assault victims. Post-traumatic stress disorder and comorbid depression among survivors of the 1999 earthquake in Turkey. Incidence and prediction of posttraumatic stress disorder symptoms in severely injured accident victims. Program Book of the 188 Anxiety and Related Disorders American College of Neuropsychopharmacology 46th Annual Meeting. Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Resting metabolic activity in the cingulate cortex and vulnerability to posttraumatic stress disorder. Role of norepinephrine in the pathophysiology and treatment of posttraumatic stress disorder. Prazosin effects on objective sleep measures and clinical symptoms in civilian trauma posttraumatic stress disorder: A placebo-controlled study. Improved cognition in Alzheimer’s disease with short-term D-cycloserine treatment. Efficacy and safety of topiramate monotherapy in civilian posttraumatic stress disorder: a randomized, double-blind, placebo-controlled study. The Transformation of Post-Traumatic Stress Disorder: From Neurosis to Neurobiology 189 Ursano, R. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Posttraumatic stress disorder and traumatic stress: from bench to bedside, from war to disaster. Long-term treatment with paroxetine increases verbal declarative memory and hippocampal volume in posttraumatic stress disorder. Prevalence of symptoms of posttraumatic stress disorder in German professional firefighters. Stiffness of large arteries and cardiovascular risk in patients with post-traumatic stress disorder. Different types of exposure to the 2004 Tsunami are associated with different levels of psychological distress and posttraumatic stress.

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In major depressive disorder generic ranitidine 150 mg visa gastritis working out, severe weight loss may occur buy discount ranitidine 150mg online congestive gastritis definition, but most individuals with major depressive disorder do not have either a desire for exces­ sive weight loss or an intense fear of gaining weight discount ranitidine 300 mg fast delivery gastritis diet 2013. Individuals with schizophrenia may exhibit odd eating behavior and oc­ casionally experience significant weight loss discount ranitidine 150 mg without prescription gastritis diet õõõ, but they rarely show the fear of gaining weight and the body image disturbance required for a diagnosis of anorexia nervosa. Individuals with substance use disorders may experience low weight due to poor nutritional intake but generally do not fear gaining weight and do not manifest body image disturbance. Social anxiety disorder (social phobia), obsessive-compulsive disorder, and body dys­ morphic disorder. If the individual with anorexia nervosa has social fears that are limited to eating behavior alone, the diagnosis of social pho­ bia should not be made, but social fears unrelated to eating behavior. Individuals with bulimia nervosa exhibit recurrent episodes of binge eating, engage in inappropriate behavior to avoid weight gain. However, unlike individuals with anorexia nervosa, binge-eating/purging type, individuals with bulimia nervosa main­ tain body weight at or above a minimally normal level. Individuals with this disorder may exhibit significant weight loss or significant nutritional deficiency, but they do not have a fear of gaining weight or of becoming fat, nor do they have a disturbance in the way they expe­ rience their body shape and weight. Comorbidity Bipolar, depressive, and anxiety disorders commonly co-occur with anorexia nervosa. Many individuals with anorexia nervosa report the presence of either an anxiety disorder or symptoms prior to onset of their eating disorder. Alcohol use disorder and other substance use disorders may also be comorbid with anorexia nervosa, especially among those with the binge-eating/purging type. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. Specify if: In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time. In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time. Specify current severity: the minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate compensatory behav­ iors per week. Diagnostic Features There are three essential features of bulimia nervosa: recurrent episodes of binge eating (Criterion A), recurrent inappropriate compensatory behaviors to prevent weight gain (Criterion B), and self-evaluation that is unduly influenced by body shape and weight (Criterion D). To qualify for the diagnosis, the binge eating and inappropriate compensa­ tory behaviors must occur, on average, at least once per week for 3 months (Criterion C). An "episode of binge eating" is defined as eating, in a discrete period of time, an amount of food that is definitely larger than most individuals would eat in a similar period of time under similar circumstances (Criterion Al). For example, a quantity of food that might be regarded as excessive for a typical meal might be consid­ ered normal during a celebration or holiday meal. A "discrete period of time" refers to a limited period, usually less than 2 hours. For example, an individual may begin a binge in a restaurant and then continue to eat on returning home. Continual snacking on small amounts of food throughout the day would not be considered an eating binge. An occurrence of excessive food consumption must be accompanied by a sense of lack of control (Criterion A2) to be considered an episode of binge eating. Some indi­ viduals describe a dissociative quality during, or following, the binge-eating episodes. The impairment in control associated with binge eating may not be absolute; for example, an individual may continue binge eating while the telephone is ringing but will cease if a roommate or spouse unexpectedly enters the room. If individuals report that they have abandoned efforts to control their eating, loss of control should be considered as present. The type of food consumed during binges varies both across individuals and for a given individual. Binge eating appears to be characterized more by an abnormality in the amount of food consumed than by a craving for a specific nutrient. Individuals with bulimia nervosa are typically ashamed of their eating problems and attempt to conceal their symptoms. The binge eating often continues until the individual is uncomfortably, or even painfully, full. Other triggers include interpersonal stressors; dietary restraint; negative feelings related to body weight, body shape, and food; and boredom. Binge eating may minimize or mit­ igate factors that precipitated the episode in the short-term, but negative self-evaluation and dysphoria often are the delayed consequences. Another essential feature of bulimia nervosa is the recurrent use of inappropriate com­ pensatory behaviors to prevent weight gain, collectively referred to as purge behaviors or purging (Criterion B). Many individuals with bulimia nervosa employ several methods to compensate for binge eating. The immediate effects of vomiting include relief from physical discomfort and re­ duction of fear of gaining weight. In some cases, vomiting becomes a goal in itself, and the individual will binge eat in order to vomit or will vomit after eating a small amount of food. Individuals with bulimia nervosa may use a variety of methods to induce vomiting, includ­ ing the use of fingers or instruments to stimulate the gag reflex. Individuals generally become adept at inducing vomiting and are eventually able to vomit at will.

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