What is Bulimia Nervosa? (Was 307.51 now F50.2)

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

What is

What is Bulimia Nervosa? (Was 307.51 now F50.2)
Photo courtesy of Pixabay.

When eating and avoiding weight gain collide.

Bulimia Nervosa, Bulimia for short, is one of the feeding and eating disorders and is diagnosed about 4 times more often than Anorexia Nervosa according to the DSM-5. For the full description consult the DSM-5, what follows is my simple language version of this disorder and my experiences in seeing clients with these issues.

Women are ten times as likely to receive this diagnosis as men. Bulimia has three defining characteristics, “pigging out” and extreme measures to make up for that episode of excessive calorie intake as well as self-esteem or self-worth that is excessively based on weight and body type. These three characteristics make Bulimia sort of like Anorexia Nervosa on the one hand and Binge Eating Disorder on the other.

Pigging out is more than just liking to eat.

What makes the pigging-out or “binge eating” different in this disorder is the feeling of loss of control. In Bulimia, the client will eat far more than would be normal and do this in a relatively short time. The official definition sets this time limit more or less at 2 hours.

So binge eating is not snacking all day or having a big appetite. It is a loss of control over how much they eat and once they start the eating run it goes on until something interrupts the binge. Some have described these loss-of-control episodes as “spacing out” or dissociating. What they binge on can be very individual and can vary from episode to episode.

This loss of control is very similar to what we see in Substance Use Disorders. Turns out that about 30 % of those with Bulimia also develop a substance use disorder. Mostly this will be alcohol which is readily and legally available and can temporarily dissolve the guilt that comes from overeating. The other common drug of choice among many people with Bulimia is a stimulant use disorder. Start off on the “Jenny-Crank” diet to lose weight and you too may develop a Stimulant Use Disorder.

Once the guilt sets in you try to undo the binge.

Characteristic of Bulimia is the use of unhealthy ways of offsetting the excess calories consumed on the binge.  Those with Bulimia may force themselves to vomit to get rid of the over-full feeling and to lose weight. They also can try laxatives, water pills (diuretics) and extreme episodes of fasting. Those fasts by the way often end with another binge.

In Bulimia, self-worth is based on weight.

All this pigging-out style overeating and then trying to make up by extreme measures is hard on the self-esteem and self-confidence. Those with Bulimia base their self-esteem and self-worth on their weight and or body. So when they put on weight, they feel bad about themselves.

Bulimia is not something that just happens during Thanksgiving week.

To be defined as Bulimia we expect this person’s dance with overeating to go on for say three months or more and they will probably be binging at least once per week. In Bulimia the revolving pattern is binge, feel bad about yourself, and then do the extreme measures to keep the weight off. The recurring story the person with Bulimia tells themselves is that if they were just thinner they would feel better about themselves and others would like them more. Unfortunately, the only way to discharge the anxiety around food is with another binge and purge.

Which eating disorder is which?

Bulimia is separated from Anorexia mostly by the person’s body weight. In Anorexia they weigh significantly less than they should and are trying to stay that way or lose even more. In Bulimia, the person weighs about normal or even a little beyond but they are defiantly not obese. In Bulimia, the main difference is that they binge and then feel they have to do extreme measures to compensate. In Binge Eating Disorder there is still the binging and the feeling bad but no compensating behaviors.

For more on this and related topics see – Feeding and Eating Disorders.

FYI These “What is” sometimes “What are” posts are my efforts to explain terms commonly used in Mental Health, Clinical Counseling, Substance Use Disorder Counseling, Psychology, Life Coaching and related disciplines in a plain language way. Many are based on the new DSM-5, some of the older posts were based on the DSM-IV-TR, both published by the APA. For the more technical versions please consult the DSM or other appropriate references.

Staying connected with David Joel Miller

Three David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

SasquatchWandering through a hole in time, they encounter Sasquatch. Can they survive? The guests had come to Meditation Mountain to find themselves. Trapped in the Menhirs during a sudden desert storm, two guests move through a porthole in time and encounter long extinct monsters. They want to get back to their own time, but the Sasquatch intends to kill them.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Books are now available on Amazon, Kobo, iBooks, Barnes & Noble, and many other online stores.

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

Advertisements

Mid-life and later life eating disorders?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Unhealthy food

Unhealthy relationship with food.
Photo courtesy of Pixabay

Why are mid-lifers and seniors developing eating disorders?

Eating disorders have traditionally been thought of as diseases of adolescence and young adulthood. Recently we think we are seeing an increase in eating disorders in middle age and older adults. Are people first developing an eating disorder as adults and if so why?

The first eating disorder to be recognized and studied was anorexia. When someone weighs less than 85% of the “average” weight for their height and age they stand out. Consider also that those average weight charts cited in some of the research may date from 1959 when most people here in the U. S. were smaller than we are now.

Bulimia was not recognized as a separate disorder until very recently and the closer we look the more eating disorders we find. Currently, a very large number of eating disorders are lumped together under the heading Eating Disorders Not Otherwise Specified (EDNOS). When the DSM-5 comes out next year (2013) there will be a whole new way of categorizing eating disorders and our understanding is likely to change.

Anorexia has long been thought of as a disease that first starts in adolescence or early adulthood. We thought it was brought on by a distorted body image or the influences of media emphasis on thinness. Anorexia is often a life long illness with relapses and can be fatal. We thought if you got out of your teen years without this illness you were home free.

We also thought that eating disorders were mostly a problem for women because of the emphasis of society on valuing women for their bodies. So when men began to be diagnosed with eating disorders this made us question what we knew about eating disorders. That change in thinking came slowly.

One study from a large European service reported in what they called a “definitive” study, that there were no cases of eating disorders that developed after age 26. I have left the name of the author of this report out from a sense of kindness. The trouble with the study was that they ended up, after looking at ten years of cases, with only eleven patients they were able to interview. Among those eleven were only one man, one person with Bulimia Nervosa and one person with EDNOS. They conclude that no one gets an eating disorder as an adult.

A study by a U. S. nonprofit of clients who were in treatment for an eating disorder in their midlife reported on a sample of 100 clients (Kally, Cumella, 2008.) They found significant incidences of late onset of an eating disorder and differences in why they may occur.

Kally & Cumella considered the question “Could these later life presentations just be people who always had the disorder but never got diagnosed and were just now reaching treatment?”

They conclude that eating disorders can and do first develop in midlife and beyond but for different reasons than those reported in samples of younger people.

They looked at three factors, background factors that predisposed the person to an eating disorder, the immediate precipitator or trigger for the episode and factors that maintain the disorder once it is established. What they found strikes me as having implications for eating disorder sufferers of all ages as well as pointing us in the direction of why more men are receiving the diagnosis these days.

The largest contributing factors they found (in my words not necessarily theirs) were a history of abuse or neglect, not just as children but at any age, and critical non-affirming people in their support system. Respondents reported that factors in the home they lived in were more important than some general societal message.

This agrees with the things many children have told me. They developed eating problems because a parent or sibling called them fat not because of some celebrities appearance. Family pressure to look a certain way, parents who controlled food or abuse substances, along with a history of abuse or neglect were some of the background reasons or risk factors for developing an eating disorder.

It takes more than a background risk factor to cause an eating disorder.

Most of the sample talked about a specific triggering event and the triggers were different for older onset cases. Children developed symptoms as a result of their family of origin problems. Those who develop eating disorders later were often triggered by events in their family of choice. So if you were abused or neglected as a child or your parents divorced you might get through the event without developing a psychiatric diagnosis. But if that sort of event happened to you as an adult, you get a divorce, then you might develop an eating disorder. People with the risk factor might show increased sensitivity to the same sort of event happening at a later point in their life.

There are more differences between early onset and late-onset eating disorders.

Adolescents are more likely to be triggered by their body image. This is the result of a natural process of growth and development. The body changes and it can be uncomfortable. This is more likely if those in your house are unsupporting or critical.

Adults develop eating disorders because of changes in the family they have created. Divorce, separation, and relationship conflicts are all triggers. As the rate of divorce increased so did the rate of adults with an eating disorder. Adults also can be triggered by health and medical issues. There was a time when there was no such thing as being too heavy. A baby who was chubby was referred to as healthy. As people live longer and become heavier we see more and more negative effects of excess weight.

Men also are feeling the effects of a shift in societal views. Overweight men are now expected to lose weight. People of both sexes have the increasing problem of weight gain caused by medications. More than ever before people are facing medication caused weight gain.

Children who were forced to diet early in life are more likely to develop a binge eating or overeating disorder in adulthood (Rubenstein, et al., 2010.) In adulthood, the number of men who develop eating disorders begins to catch up with the number of women (Keel et al., 2010.)

The eating disorder conclusion.

Young people develop eating disorders because of a faulty or poor body image. Adults, as they get older, develop eating disorders because they do not like the changes in their bodies and in their life that aging cause.

What are your thoughts about why mid-lifers and seniors are developing eating disorders?

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

6 new Eating Disorder Traits

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Unhealthy food

Unhealthy relationship with food.
Photo courtesy of Pixabay

New eating disorders that did not make the cut.

Update.

The DSM-5 is out now. some of the proposed changes did not happen. The NEC became other specified and other unspecified. I have left this post up as it reflects the thinking in the field but for the latest official diagnostic criteria consult the new DSM-5.

Beginning in 2013 when the DSM-V appears the mental health diagnostic landscape will change. We have known for a long time that the current way of understanding Eating Disorders has left out a lot of people who had problems in their relationships with food and weight.

The old way of seeing things, that eating disorders consisted of Anorexia Nervosa and Bulimia just didn’t fit the majority of people who a therapist might see who had problems around food and weight. In some outpatient clinics, more people got the diagnosis of Eating Disorder Not Otherwise Specified (NOS) than got a specific diagnosis. All that is about to change.

One way of cutting down on the overuse of a diagnosis is to just delete it. The Eating Disorder NOS will suffer this fate.

The new label will be Eating Disorder Not Elsewhere Classified (NEC.) The difference will be the creation of 6 new “types” or conditions. This is similar to the way we have been doing Personality Disorder symptoms that are not quite severe enough to be full disorders, we just call them “traits.”

The new conditions, in my order of explanation not the APA’s order, are:

A. Purging disorder

This will require that they purge to lose weight but will not include binging behaviors. This separates Purging Disorder from Bulimia.

B. Night Eating Syndrome

People who do this get upset about it; upset enough to go for treatment so I think this one is an improvement. The current description reminds me of cravings associated with addiction or impulse control problems.

With Night Eating Syndrome you wake up, you eat and you remember eating. It is not the same as emotional eating. After the night eating, you get upset about this behavior. The episode is not the result of changes in your sleep or eating pattern.

C. Atypical Anorexia Nervosa

In this condition, the person does everything a person with anorexia does but their weight does not drop below the magic 85% of normal. Hope the APA gives us some more to go on here. I can see how separating this from Avoidant Restrictive Food Intake disorder might be confusing.

D. Subthreshold Bulimia Nervosa

Same as Bulimia Nervosa but they don’t do the binging and compensating behaviors as often or for as long. The efforts to compensate for binging are less than once per week and/or last less than 3 months. This reminds me of depression with mild, moderate and severe categories.

E. Subthreshold Binge Eating Disorder

Like Binge Eating Disorder but not often enough or over a long enough period of time to be sure it is Binge Eating Disorder. The binges are less than once per week and/or last less than 3 months.

F. Other Feeding or Eating Condition Not Otherwise Classified

This is a place to put anything that does not fit another eating diagnosis but needs attention. As a result of all the changes in the DSM-5, new diagnoses, the conditions listed under not otherwise classified and the inclusion of some childhood things that used to be separated from eating disorders there will be a whole lot less ending up here. Effectively this should empty out all those miscellaneous NOS diagnoses.

Other posts about eating disorders and the new DSM-V proposals will be found at:

Binge Eating Disorder – the other side of Anorexia and Bulimia 

Middle class and starving to death in America – An Eating Disorder called Anorexia

Love Hate relationship with food – Bulimia Nervosa

Eating Disorders and Substance abuse  

Avoidant Restrictive Food Intake Disorder

Do any of these eating disorder traits fit you or someone you know?  Feel free to leave a comment. If any problem with weight or eating is affecting your job, relationships or making you unhappy, consider seeing a professional.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

Binge Eating Disorder – the other side of Anorexia and Bulimia

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

What is

Binge Eating Disorder – the other side of Anorexia and Bulimia
Photo courtesy of Pixabay.

Eating yourself to death – Binge Eating Disorder.

We used to ignore Binge Eating and only pay attention to eating disorders that involved inappropriate ways to control weight. Anorexia and Bulimia are well-recognized eating problems that were covered in previous posts.

Other posts about eating disorders and the new DSM-V proposals will be found at:

Binge Eating Disorder – the other side of Anorexia and Bulimia 

Middle class and starving to death in America – An Eating Disorder called Anorexia

Love Hate relationship with food – Bulimia Nervosa

Eating Disorders and Substance abuse  

Avoidant Restrictive Food Intake Disorder

Recently we have started to see how the overeating part can be a major issue even without the effort to control weight. In Binge Eating Disorder the emotional eating component takes place but it is as if the person with Binge Eating Disorder gives up and stops even trying to control their weight.

As in Bulimia, the food is consumed in a relatively short period of time, two hours or less. One episode of this behavior does not make for the diagnosis; Binge Eaters do these behaviors on a regular basis. The strict diagnostic criterion calls for at least one episode a week for at least three months.

Loss of control is a hallmark of this as well as other impulse control problems. It is not simply that the person likes to eat but that they are driven to eat. Even when they try to avoid the excess calories they are unable to control themselves.

Binge eaters eat faster than everyone else, they wolf the food down. And the Binge eater does not stop when full. They are unable to realize they are full until it becomes impossible to eat more. Even when not hungry the Binge eater will continue to eat for the emotional values of the experience rather than for the nutritional ones.

This eating disorder like other eating disorders is characterized by secrecy and avoiding others seeing what the Binge Eater is doing, they will eat surreptitiously to avoid notice. After a binge episode, the Binger may become sad, anxious and have feelings of guilt. They can begin to hate themselves.

Binge eaters are not comfortable with what they are doing, they wish they could stop but efforts to control their food intake are unsuccessful.

Binge eating is not a simple case of overeating, laziness or unwillingness to exercise. It is a specific psychiatric problem that includes the uncontrollable urge to eat even when full and the lack of any energy to attempt to lose weight.

Binge Eating may lead to depression or may accompany a mood disorder. Gradually the pounds are packed on; the Binge eater becomes isolated from family and friends and may begin to hate themselves but still can’t stop without help. This condition requires professional treatment. Treatment for Binge eating may be less widely available than therapy for other eating disorders because the health damage occurs more slowly, but untreated the ill effects on health will certainly occur.

There is a fourth category of Eating disorders, Eating Disorders Not Otherwise Specified (NOS) which includes both unusual problems in food and weight loss and those cases that are not quite severe enough to get a diagnosis of one of the three principal types.

Three brief posts to cover four potential problems in the area of food and eating. There is treatment available for all of these issues. If you have experienced an eating disorder and care to share your experience, strength, and hope please leave a comment about anything related to Anorexia, Bulimia Binge Eating Disorder or any other topic related to recovery.

Staying connected with David Joel Miller

Three David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

SasquatchWandering through a hole in time, they encounter Sasquatch. Can they survive? The guests had come to Meditation Mountain to find themselves. Trapped in the Menhirs during a sudden desert storm, two guests move through a porthole in time and encounter long extinct monsters. They want to get back to their own time, but the Sasquatch intends to kill them.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Books are now available on Amazon, Kobo, iBooks, Barnes & Noble, and many other online stores.

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

Love Hate relationship with food – Bulimia Nervosa.

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Unhealthy relationship with food.
Photo courtesy of pixabay

Bulimia Nervosa a relapsing eating disease.

Bulimia Nervosa is included in the eating disorder category along with Anorexia Nervosa but it is very different from the other eating disorders. Anorexia progresses like a vice, starving the sufferer until their weight reaches a critical potentially fatal low. Bulimia runs its course in episodes of extreme eating and efforts to undo the overeating and lose the weight until it finally does its damage.

If you didn’t hear the person with Bulimia talking about food, should you only hear the emotional component, it would be hard to distinguish Bulimia from the binge drinking form of alcoholism.

Episodes of binging and the resulting guilt can be triggered by many of the same things that trigger addictive binges. Poor relationships and conflicts with others, the feeling of deprivation from excessively strict diets, or feeling out of control all can trigger the binges.

Binge eaters describe these overwhelming obsessive-compulsive urges as emotional eating. Emotional eaters who do not purge develop Binge Eating Disorder. Those who start compensating develop Bulimia.

Most people who develop Bulimia start off at normal or even a little overweight. They are likely to be a little older than the beginning person with Anorexia, perhaps late teens or even early twenties. There may be a period of moderate to strict dieting before the Bulimia strikes.

When they diet they have increasingly intense urges to eat. The tension continues to grow until the individual can’t stand it any longer, then like the alcoholic, the binge is on. At this point, the “just don’t think about it” approach does not work and may make things worse. In a previous post “Don’t think about Elephants.”   I described why the “just not thinking about things” approach does not work and what else can be done in this circumstance.

Binge drinking is defined as 4-5 drinks on a single drinking occasion, enough to get intoxicated. Binge eating is described as eating far more than a normal person during a single food intake episode lasting two hours or less. Bulimics crave food and then when they give in and eat it is not a little, but a lot of food consumed in a short amount of time. This overconsumption results in guilt and regret.

These episodes increase in frequency. Typically the person with Bulimia will have two or more episodes of loss of control, binge eating and then efforts to purge the food every week for at least three months. The guilt over the episode increases the risk they will binge again.

Often the food of choice is ice cream or cake though no one food type is the choice of all people with Bulimia. They will eat until they reach the over-full point, become uncomfortable or even painfully full.

The Bulimic then tries to undo the excess calories by deliberate vomiting or other compensatory behaviors. This is not a disease of gradual overeating and excess weight gain. Bulimia may result in sudden swings in weight, both increases, and decreases. The damage comes not from the weight gain or loss but from the radical behaviors used to undo the binge episode.

The emphasis is on the person’s use of “inappropriate” methods to undo the overeating. Someone with Bulimia may vomit so often that the enamel in the teeth is destroyed. They may develop calluses on the knuckles from repeated efforts to force the vomiting.

There can be damage to the throat and esophagus. A great many medical problems develop over time but may go unnoticed as the person’s weight swings up and down rather than moving to an extreme.

Bulimia is more common than Anorexia with up to three percent of women developing Bulimia during their lifetime.

These episodes of binge eating and the resulting efforts to undo the overeating are generally done in secret. The sufferer tries to be inconspicuous and may withdraw from family and friends damaging their relationships.

Self-esteem for the person with Bulimia is dependent on body shape and weight. They often develop intense depression after a period of bingeing and purging. Some have undiagnosed depression before the Bulimia, but Bulimia can also cause depression and anxiety.

Bulimia Nervosa like Anorexia Nervosa is treatable but both require specialized treatment by someone knowledgeable and experienced in treating eating disorders.

Bulimia is not associated with a high risk of suicide or death from medical complications, though some who have suffered from Bulimia can become severely depressed and have thoughts of self-harm.

Bulimia Nervosa is an illness not a case of vain or selfish behavior. If you want to be helpful to someone with this disorder listen to what they have to say in an open and non-judgmental way.

If you have Bulimia, get help now. If you know someone who has this problem encourage them to seek professional help.

Other posts about eating disorders and the new DSM-V proposals will be found at:

Binge Eating Disorder – the other side of Anorexia and Bulimia 

Middle class and starving to death in America – An Eating Disorder called Anorexia

Love Hate relationship with food – Bulimia Nervosa

Eating Disorders and Substance abuse  

Avoidant Restrictive Food Intake Disorder

Staying connected with David Joel Miller

Three David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

SasquatchWandering through a hole in time, they encounter Sasquatch. Can they survive? The guests had come to Meditation Mountain to find themselves. Trapped in the Menhirs during a sudden desert storm, two guests move through a porthole in time and encounter long extinct monsters. They want to get back to their own time, but the Sasquatch intends to kill them.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Books are now available on Amazon, Kobo, iBooks, Barnes & Noble, and many other online stores.

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.