Bulimics can be under, over, or of normal weight. Bulimia is also distinguished from binge eaters who do not engage in compensatory behavior afterwards.
The numbers of people suffering from bulimia is difficult to determine. "Research suggests that about four percent (4%), or four out of one hundred, college-aged women have bulimia. About 50% of people who have been anorexic develop bulimia or bulimic patterns" ("Statistics: How many people have eating disorders?" ANRED, 2007). Other estimates range around 3% (Rowan, 2006). The causes of Bulimia Nervosa are even more difficult to pinpoint. Some therapists believe that "the pressure to be thin and resulting abnormal eating patterns that are regarded as normal are probably partly to blame," and individuals in appearance-conscious jobs or weight-conscious sports such as wrestling, gymnastics, and running, have a higher incidence of bulimia (Rowan, 2006). Also, estern countries have higher rates of eating disorders than non-estern countries,…...

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Works Cited

Anorexia Nervosa" Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition, Text Revision. American Psychiatric Association.2000.7 May 2007. http://www.poppink.com/dsmiv/7.html

Bulimia Nervosa." Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition, Text Revision. American Psychiatric Association.2000. 7 May 2007. http://www.poppink.com/dsmiv/13.html

Bulimia is a serious eating disorder, but it does not get the same media coverage or understanding as anorexia. One of the reasons for that is that bulimic patients are typically a normal weight. People around them may not realize they have a problem or that they suffer from disordered eating of any kind. Those who have bulimia are characterized by a cycle of binging on food and then purging through vomiting or the use of laxatives (Hay & Claudino, 2010; Palmer, 2004). Some bulimics also take stimulants or diuretics, and they may exercise excessively (Hay & Claudino, 2010). Because the people around them see them eating relatively normally, they may not realize there are serious physical and psychological issues at play. The bulimic individual, though, generally knows that his or her disordered eating patterns are not normal. Depending on the reasons behind the eating disorder, he or she may…...

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References

Hay, P.J. & Claudino, A.M. (2010). Bulimia nervosa. Clinical Evidence: 1009.

Palmer, R. (2004). Bulimia nervosa: 25 years on. The British Journal of Psychiatry, 185(6): 447 -- 8.

Patton, G.C., Coffey, C., Carlin, J.B., Sanci, L., & Sawyer, S. (2008). Prognosis of adolescent partial syndromes of eating disorder. The British Journal of Psychiatry, 192(4): 294 -- 9.

Russell, G. (2009). Bulimia nervosa: An ominous variant of anorexia nervosa. Psychological Medicine, 9(3): 429 -- 48.

" (National Institute of Mental Health, 2009)
III. RISK FACTORS and COMPLICATIONS

Factors playing a role in ulimia are stated to be those as follows:

cultural pressures;

family, as bulimia tends to run in families;

life changes or stressful events;

The individual's psychological makeup;

iological aspects such as genes, hormones, and brain chemicals. (U.S. Department of Health and Human Services, 2007)

IV. EFFECTS

Individuals with bulimia often have "swollen cheeks or jaw area" as well as rough skin on their knuckles and teeth that appear clear. (U.S. Department of Health and Human Services, 2007) it is also noted by the U.S. Department of Health and Human Services that individuals with ulimia often have broken blood vessels in their eyes. (U.S. Department of Health and Human Services, 2007)

The effects of ulimia Nervosa on the individual's body are shown in the following illustration labeled Figure 1 as shown in the following illustration are many negative affects on the body of the…...

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Bibliography

Bulimia Nervosa (2009) National Institute of Mental Health. 1 Jan 2009. Online available at  http://www.nimh.nih.gov/health/publications/eating-disorders/bulimia-nervosa.shtml 

Bulimia Nervosa (2007) U.S. Department of Health and Human Services, Office on Women's Health. July 2007.

Brain Circuit Abnormalities May Underlie Bulimia Nervosa in Women (2009) ScienceDaily - Science News 7 Jan 2009. Online available at  http://www.sciencedaily.com/releases/2009/01/090105175031.htm 

Bulimia Nervosa

Taylor et al. (2006) investigated the effectiveness of an internet-based psychological intervention for the prevention of eating disorders among young women who may be at-risk due to their pronounced body weight and shape concerns. The results of the study indicated that individuals were less concerned about their weight following participation in the online program. Specifically, the 8-week, internet-based cognitive-behavioral intervention was found to significantly reduce concerns regarding shape and weight for a period of up to 2 years and decrease the risk for development of eating disorders among high-risk groups. The authors claimed that their study was the first of its kind to effectively demonstrate that there are means of preventing the onset of eating disorders in high-risk groups.
eferences

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatric Association (1994).

Bacaltchuk, J., Hay, P., Trefiglio, . "Antidepressants vs. Psychological Treatments and Their Combination for…...

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References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatric Association (1994).

Bacaltchuk, J., Hay, P., Trefiglio, R. "Antidepressants vs. Psychological Treatments and Their Combination for Bulimia Nervosa." Cochrane Database of Systematic Reviews 4 (2001): CD003385.

Lamb, J. "Bulimia Nervosa." The Gale Encyclopedia of Medicine. Eds. Olendorf, O.; Jeryan, C.; and Boyden, K. Farmington Hills, MI: Gale Research, 1999.

McGilley, B.M., Pryor, T.L. "Assessment and Treatment of Bulimia Nervosa." American Family Physician 57 (1998): 2743-50.

Treatments of ulimia Nervosa
THE EST OPTION

Evaluation of Combined Therapy for ulimia Nervosa

Description and Significance

ulimia nervosa, simply bulimia or N, refers to uncontrolled overeating or binging and then eliminating what has been eaten (SJH, 2012; Grange et al., 2004). Recent reports show alarming increases in the incidence, which now adolescents and pre-adolescents. The latest population statistics say that about 27.3 of the U.S. population is between 12 and 19 years old. N affects up to 3% of these young people 15-18 years old at peak (SJH, Grange et al.).

rief Description of N

N consists of eliminating or purging ingested food through induced vomiting, inappropriate use of laxatives or diuretics, fasting or extreme exercise to control weight (SJH 2012; Grange et al., 2004). The exact cause or causes are still unknown. ut some factors are believed to contribute to it. These are cultural ideals and social attitudes about body appearance, self-evaluation on the…...

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BIBLIOGRAPHY

Blake, J. G and Rich, J. (2008). Which drugs are most effective for moderate to severe depression in adolescents? Vol 57 # 5 The Journal of Family Practice: Quadrant

Health Com. Inc. Retrieved on February 29, 2012 from http://www.jfponline.com/Pages.asp?AID-6182

Brent et al. (2008). Switching to another SSRI or to Venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression.

The Journal of the American Medical Association: American Medical Association.

Clinical Psychology / Bulimia Nervosa
The beginnings of clinical psychology date back to the year 1492, and it has changed from the mere treatment of mental illness to an entire field of research and experimentation, which has helped those individuals who have been affected by any form of mental disorders, like for example, the eating disorders like bulimia nervosa and anorexia nervosa prevalent among adolescent and twenty-year-old women all over the world, to overcome their habits so that they may lead better and more productive lives. Some of the more important names in the history of clinical psychology, who can be referred to as the founding fathers of the field, are Lightner Witmer and Wilhelm Wundt. It was their theories and methods that has paved the way for the clinical psychologists of today, who are today being trained to encompass more issues like the entire range of health care, for the…...

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REFERENCES

Arnet, John. L. (February, 2001) "Clinical and Health Psychology, future directions"

Canadian Psychology. Retrieved From

 http://findarticles.com/p/articles/mi_qa3711/is_200102/ai_n8932880 

Accessed 12 October, 2005

Experimental Methodologies: Bulimia Nervosa
Annotated Bibliography in Abnormal Psychology

Bara-Carril, Nuria, Williams, Christopher J., Pombo-Carril, Maria G., Reid, Yael, Murray, Kathryn, Aubin, usan et al. (2004). A preliminary investigation into the feasibility and efficacy of a CD-ROM-based cognitive-behavioral self-help intervention for bulimia nervosa. International Journal of Eating Disorders, 35(4), 538-548.

A quasi-experimental study was carried out to test the efficacy of a CD-ROM-based CBT self-help intervention for bulimia. ubjects with a diagnosis of bulimia (N = 36) or eating disorder not otherwise specified (EDNO; N = 9) were recruited as they presented at an eating disorders clinic in outh London. The EDNO patients met all the criteria for bulimia except for the frequency of binge eating and purging behavior. The exclusion criteria included an inability to understand English, anorexia nervosa, psychosis, acutely suicidal, current substance abuse, severe learning disability, and an inability to attend sessions. Treatment consisted of eight sessions interacting with the…...

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Schapman-Williams, Ann M. And Lock, James. (2007). Using cognitive-behavioral therapy to treat adolescent-onset bulimia nervosa: A case study. Clinical Case Studies, 6(6), 508-524.

In an effort to provide a rationale for future large studies, Schapman-Williams and Lock presented a case study of a 16-year-old female Caucasian with bulimia being treated with CBT. The symptoms began 18 months prior to appearing at the clinic, starting with a concern about the need to lose weight. Food restriction and over-exercise was followed by purging through vomiting. Body image distortion and binge eating also developed. By the time she presented at the clinic, the binge-purge cycle was occurring 2-3 times per day. When given a choice between CBT and interpersonal therapy, the patient and parent chose CBT. A standard course of 20 therapy sessions for treating bulimia was prescribed.

By the second therapy session the eating pattern had begun to normalize, a process that was completed by session 12. The binge-purge cycles ended immediately, with only one relapse reported at session 13. Although the patient experienced a slight weight gain between sessions 5 and 6, weight was stable throughout treatment. Self-reports of eating associated distress declined rapidly and was gone by session 9. The study limitations mentioned by the authors included the use of a treatment protocol intended for adults, but the treating therapists were able to adapt by involving the patient's mother, in an effort to make the home environment more conducive to treatment goals. The results of this study suggest that treating adolescent-onset bulimia using CBT for adults is effective.

They also tended to have mothers who were concerned about their own weight, and who chronically dieted to control their own weight. Many young women with eating disorders also exhibit lower self-esteem and anxiety. Families may actually contribute to the disorder by admiring the sufferers' thinness and ability to exercise "control" over their eating habits.
Bulimics also have several common characteristics. They tend to be from the same social group as anorexics, and they tend to come from families with a history of weight problems or concerns. In fact, many bulimia patients have mothers with more body mass, and this factor is inheritable, so bulimia, or the physical aspect of it, can run in families. In addition, family members often remember bulimia patients being heavier or larger in late childhood and into adolescence. A history of teasing also tends to be common in these patients (Smolak, Levine, and Striegel-Moore 287).…...

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References

Polivy, Janet, and C. Peter Herman. "Causes of Eating Disorders." Annual Review of Psychology (2002): 187+.

Smolak, Linda, Michael P. Levine, and Ruth Striegel-Moore, eds. The Developmental Psychopathology of Eating Disorders Implications for Research, Prevention, and Treatment. Mahwah, N.J.: Lawrence Erlbaum Associates, 1996.

Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder, Night Eating Syndrome and Eating Disorders Not Otherwise Specified
Eating disorders are psychological illnesses associated with a host of adverse medical conditions, negative psychological affects, and substantial reductions in quality of life. This paper will explore some of the causes research has attributed to this behavior. According to Leslie Sim, et al. (2010) the main eating disorders are anorexia nervosa, bulimia nervosa, binge-eating disorder, night eating syndrome and eating disorders not otherwise specified.

Anorexia Nervosa

Anorexia nervosa is described as abnormally low body weight of at least 15% below what would be expected and a corresponding fear of weight gain with an undue emphasis on weight and shape in self-evaluation. The incidence of anorexia nervosa is approximately 0.5% to 1% and is highest among adolescent girls and young women. Anorexia nervosa can be classified into 2 subtypes, the restricting subtype and the binge-eating/purging subtype. Patients…...

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References

Bardone-Cone, A.M., Schaefer, L.M., Maldonado, C.R., Fitzsimmons, E.E., Harnby, M.B., Lawson, M.A., Robinson, D.P., Tosh, A., & Smith, R. (2010, September). Aspects of self-concept and eating disorder recovery: What does the sense of self look like when an individual recovers from an eating disorder? Journal of social & clinical psychology. Vol. 29, Issue 7, 821-846. Retrieved January 15, 2012 from   BC-8cc9-57c44d9d4527%40sessionmgr14http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=3&hid=17&sid=a2184cd5-bd30-41 

Cooper, M.J. & Cowen, P. (2009, Summer). Negitive self-beliefs in relation to eating disorder and depressive symtoms: Different themes are characteristic of two sets of symtoms in those with eating disorders and/or depression. Journal of cognitive psychotherapy. Vol. 23, No. 2, 147-159. Retrieved January 15, 2012 from  http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=3&hid=15&sid=174e3795-cce7-45ea-9035-ee209cd2d8c2%40sessionmgr12 

Demidenko, N., Tasca, G.A., Kennedy, N. & Bissada, H. (2010, December). The mediating role of self-concept in the relationship between attachment insecurity and identity differentiation among women with eating disorder. Journal of social and clinical psychology. Vol. 29, No. 10, 1131-1152. Retrieved January 15, 2012 from  http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=3&hid=107&sid=e1322b21-ca54-4265-82de-2c2eb6e21557%40sessionmgr112 

Erguner-Tekinalp & Gillespie, C.W. (2010, Fall). Mental health practitioners' professional opinions of etiology of eating disorders. International journal of mental health. Vol. 39, No. 3, 68-87. Retrieved January 15, 2012 from  http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=3&hid=15&sid=6580eaf0-748f-465e-a92e-3ae449dfe4d1%40sessionmgr14

What is bulimia? Bulimia falls under types of eating disorders where the victim experiences regular intervals of heavy eating or bingeing in which time the affected person is unable to control their eating (Fairburn, Christopher and Harrison, 407–416). The affected person can employ various avenues such as purging (laxatives) or vomiting as a way of avoiding weight gain. A good number of people suffering from Bulimia also suffer from anorexia. Anorexia, according to Treasure et al. (2015), happens to be a psychiatric disorder in which the affected person experiences serious weight loss and tertiary problems relating to malnutrition. Adolescence age is the most likely period people suffer from it.
People suffering bulimia can also do excessive exercises to try and keep their weight in check. During the purging period the person suffering from Bulimia disorder can lose control of them and get involved in hysterical attempts aimed at undoing their feelings (Graves,…...

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Works Cited

“Eating Disorder Hope.” Bulimia Nervosa: Causes, Symptoms, Signs & Treatment Help. 2018. < Accessed, 29. Sep. 2018

“Eating Disorder Hope.” Bulimia and Teenagers: Risks, Dangers, and Complications. 2018 <https://www.eatingdisorderhope.com/information/bulimia/bulimia-and-teenagers-risks- dangers-and-complications> Accessed, 29. Sep. 2018

Fairburn, Christopher G, and Paul J Harrison. “Eating Disorders.” The Lancet 361.9355 (2003): 407–416. The Lancet. Web.

Graves, Bonnie B. Bulimia. Mankato, MN: Capstone Press, 2000. Print.

Parks, Peggy J. Teenage Eating Disorders. , 2012. Internet resource.

Stewart, Gail B. Bulimia. Place of publication not identified: Cherry Lake Publishing, 2014. Internet resource.

Treasure, Janet et al. “Anorexia Nervosa.” Nature Reviews Disease Primers 26 Nov. 2015. Nature Reviews Disease Primers. Web.

https://www.eatingdisorderhope.com/information/bulimia>,

AbstractThe below literature review will discuss the theories of body image perception as it relates to bulimia nervosa. The document will discuss the implication of social media on the perception of the idea of beauty in the minds of young women. Social media, particularly, the idea of perfection and how unrealistic it is to obtain will be observed using peer-reviewed articles. Likewise, the role of societal pressures related ideal weight, size and shape will also be reviewed. Finally, the overall science behind bulimia nervosa will be discussed with a particularly emphasis on the psychological implication of peer approval.For one all of these elements are heavy correlated the bulimia nervosa. Young women are particularly susceptible to this disorder as their brains are still developing. Here, young women attempt to make sense of the various stimuli around them, namely advertisements, social norms, social media, and peers. As research will attest, female peers…...

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References 1. Sattler, F. A., Eickmeyer, S., & Eisenkolb, J. (2020). Body image disturbance in children and adolescents with anorexia nervosa and bulimia nervosa: A systematic review. Eating and Weight Disorders, 25(4), 857–865.   Vaughn, A. A., & Lowe, J. D. (2020). With age comes responsibility: Changes in stigma for boys/men with bulimia nervosa. Eating and Weight Disorders, 25(6), 1525–1532.  https://link.springer.com/article/10.1007/s40519-019-00786-6 3. Benninghoven, D., Raykowski, L., Solzbacher, S., Kunzendorf, S., & Jantschek, G. (2007). Body images of patients with anorexia nervosa, bulimia nervosa and female control subjects: A comparison with male ideals of female attractiveness. Body Image, 4(1), 51–59. https://www.sciencedirect.com/science/article/pii/S1740144506001148?via%3Dihub4. Katan, A., & Kelly, A. C. (2021). A two?week daily diary study examining the association between daily self?compassion and symptoms of bulimia nervosa. International Journal of Eating Disorders, 54(8), 1438–1448. https://onlinelibrary.wiley.com/doi/10.1002/eat.235335. Perkins, N. M., & Brausch, A. M. (2019). Body dissatisfaction and symptoms of bulimia nervosa prospectively predict suicide ideation in adolescents. International Journal of Eating Disorders, 52(8), 941–949.https://onlinelibrary.wiley.com/doi/10.1002/eat.231166. Rühl, I., Legenbauer, T., & Hiller, W. (2011). The impact of exposure to images of ideally thin models in TV commercials on eating behavior: An experimental study with women diagnosed with bulimia nervosa. Body Image, 8(4), 349–356. https://www.sciencedirect.com/science/article/pii/S17401445110009457. Grilo, C. M., Ivezaj, V., Lydecker, J. A., & White, M. A. (2019). Toward an understanding of the distinctiveness of body-image constructs in persons categorized with overweight/obesity, bulimia nervosa, and binge-eating disorder. Journal of Psychosomatic Research, 126. https://www.sciencedirect.com/science/article/pii/S002239991930039X?via%3Dihub8. Grilo, C. M., Crosby, R. D., & Machado, P. P. P. (2019). Examining the distinctiveness of body image concerns in patients with anorexia nervosa and bulimia nervosa. International Journal of Eating Disorders, 52(11), 1229–1236. https://onlinelibrary.wiley.com/doi/10.1002/eat.231619. Lenroot, R. K., & Giedd, J. N. (2010). Sex differences in the adolescent brain. Brain and cognition, 72(1), 46–55.  https://doi.org/10.1016/j.bandc.2009.10.008 2https://link.springer.com/article/10.1007%2Fs40519-019-00725-5 2.

Anorexia and Bulimia
Factors Influencing the Incidence of Anorexia and Bulimia

The two primary eating disorders in Western countries are anorexia nervosa and bulimia nervosa. Women constitute the primary sufferers of these diseases, with 0.5% to 3.7% and 1% to 3.7% suffering from anorexia and bulimia, respectively (Scott, Hardman, and Berrett, 2007, p. 14). Men also suffer from these eating disorders, but at about one-tenth the rate.

Anorexia is defined by a subnormal body weight (...

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References

Scott, Richards P., Hardman, Randy K., and Berrett, Michael E. (2007). Spiritual Approaches in the Treatment of Women with Eating Disorders. Washington, D.C.: American Psychological Association.

Treating Adolescents With Anorexia Nervosa
Anorexia nervosa is an eating confusion described by a terror of fatness experienced during the adolescence period that leads to them to starving themselves leading to harmful low body weight, a moody fear of being fat and compulsive hunt for thinness. Though not limited to a certain age or sex, it mostly affects the female. The eating disorder affects both the physical appearance; thin appearance and psychological health. Though the origin of anorexia nervosa is blurred, severe fasting and weight loss are regularly linked with efforts to manage the increasing psychological and social burden of adolescence, the disorder leads to a reported death rate of 6-10% of the adolescent who do not seek medication in time Berkman et al., 2006.

The worry among most clinicians is whether to focus on anxieties the adolescence have during this period of growth or addressing the rigorous dieting and weight loss.…...

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Reference

Berkman, N.D., Bulik, C., Lohr, K., Brownley, K., J., S., Rooks, A., & Gartlehner, G. (2006). Management of Eating Disorders. North Carolina: AHRQ Publication.

Cachelin, M., & Rebeck, R. (2000). Barriers to Treatment for Eating Disorders among Ethnically Diverse Women. California: Wesleyan press.

Lock, J., Couturier, J., & A., S.W. (2006). Comparison of Long-Term Outcomes in Adolescents With Anorexia Nervosa Treated With Family Therapy. Ontario: DOI press.

Shepphird, S.F. (2010). 100 questions & answers about anorexia nervosa. Sudbury: Jones and Bartlett Publishers.

Young people with poor eating habits can develop eating disorders or these disorders may be in response to various psycho-sociological issues that arise during adolescence. Irrespective of the cause, adolescents with eating disorders run the risk of a wide range of adverse healthcare outcomes, including obesity, high blood pressure, bone loss and even death. The problem is more common than many people believe, and the prevalence of eating disorders has been increasing in recent years due in part to improved recognition of the condition by clinicians. To determine the current state of affairs with adolescent eating disorders, this paper provides a review of the relevant peer-reviewed and scholarly literature to develop a background and overview of eating disorders, their effects and how these conditions are treated. Finally, a summary of the research and important findings about adolescent eating disorders are provided in the conclusion.
Background and Overview

Professional and public awareness of…...

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References

Cariun, C., Taut, D., & Baban, A. (2012, March). Self-regulatory strategies for eating behavior in children and adolescents: A concept mapping approach. Cognitie, Creier,

Comportament, 16(1), 49-54.

Enos, G.A. (2013, March/April). Addressing eating disorders earlier. Addiction Professional,

11(2), 40.

Motivation to Change and eduction of Symptoms in Adolescents Suffering from Bulimia Nervosa
In research published by Castro-Fornieles (et al., 2011) the relationship between recovery from bulimia nervosa and motivation to change in adolescence sufferers is examined. The authors of the research had not found any similar research which had looked at this specific area of study. However, the research is based on previous research where strong links between behavioral changes in adults suffering from eating disorders and level of motivational for change. The importance of motivation has been generally accepted as an important influence and predictor of successful change in a range of health issues, such as smoking, which rely on patients implementing and maintaining behavioral changes. When looking specifically as bulimia nervosa, further research has found that relapses are more likely where adults suffering from the condition. In adolescents there has also been research examining motivation and the…...

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Reference

Castro-Fornieles, Josefina,; Bigorra, Aitana; Martinez-Mallen, Esteve; Gonzalez, Laura; Moreno, Elena; Font, Elena; Toro, Josep, (2011), Motivation to change in adolescents with bulimia nervosa mediates clinical change after treatment, European Eating Disorders Review, 19, 46-54

Ethicality and Efficacy of Compulsory Treatment for Eating Disorders
Introduction:
Eating disorders, such as anorexia nervosa and bulimia nervosa, are severe mental illnesses that can have life-threatening consequences. Due to the high mortality and morbidity rates associated with these disorders, there has been considerable debate about the ethicality and efficacy of compulsory treatment. This essay will examine the literature that supports the ethicality and efficacy of compulsory treatment for eating disorders.
Ethical Considerations:
Individual Autonomy vs. Public Health Concerns:
Compulsory treatment involves restricting an individual's freedom by mandating therapy or hospitalization. However, it can be argued that the public health concerns associated with eating....

1. Anorexia nervosa is an eating disorder characterized by an intense fear of gaining weight, a distorted body image, and severe food restriction

2. Bulimia nervosa is an eating disorder characterized by binge eating followed by purging, such as vomiting or using laxatives

3. Binge eating disorder is characterized by recurrent episodes of binge eating, in which a person consumes a large amount of food in a short period of time

4. Eating disorders are serious mental illnesses that can have devastating consequences, including death

5. People with eating disorders often have a distorted body image, and may see themselves as overweight even when....