What Are Eating Disorders?
Eating disorders are problems that affect a person’s mental health and are defined by unhealthy, compulsive, or disordered eating behaviors. Eating disorders include anorexia nervosa (voluntary starving), bulimia nervosa (binge-eating followed by purging), binge-eating disorder (binge-eating without purging), and other or unnamed eating disorders. Eating disorders come with both mental and physical symptoms (disordered eating patterns that do not fit into another category).
Eating disorders are more prevalent in societies with higher levels of wealth than in communities with lower levels of wealth, but this does not mean that only wealthy people suffer from them. Although a disproportionate percentage of people diagnosed with eating disorders are young women in their teens and 20s, anybody may acquire an eating problem. This includes young males and elderly persons of any gender. Eating disorders often become all-consuming, compelling those who suffer from them to concentrate only on eating (or not eating) to the cost of many other aspects of their lives.
Some of the variables that might contribute to eating disorders include biological factors, social and interpersonal stressors, and a history of the condition in the family. Concerns about one’s body image that are influenced by culture, together with personality factors such as perfectionism and obsessiveness, also play a significant part in the development of these illnesses, which are often accompanied by anxiety or despair.
In most cases, treatment is not easy. Eating disorders may result in further medical issues and, in extreme cases, can even pose an immediate risk to a person’s life, necessitating hospitalization and the administration of artificial nutrition. For patients to make a complete recovery, it is frequently necessary for them to work with a team of health specialists from a variety of fields, including psychotherapists, medical physicians, and specialized dietitians or nutritionists.
Signs and Symptoms of Eating Disorders
Eating disorders are characterized by abnormalities in a person’s relationship with food as well as their perception of their own body and weight. However, these disruptions might present themselves in a wide variety of ways. In certain circumstances, such as when someone suddenly loses a significant amount of weight or when they refuse to eat, the symptoms may be easily recognized. In other situations, the warning signs might be more subtle, such as when a person begins to adhere to strict routines about their meals, such as only eating certain foods or at specified times, or when they start exercising excessively. In some cases, however, the symptoms of the illness may not be obvious. For example, someone with bulimia could use the lavatory after meals, but someone with a binge-eating disorder would eat in solitude.
The illness is also capable of causing or exacerbating symptoms related to a person’s mental health. People who suffer from eating disorders often have difficulties with mood swings and anxiety. They may also become more reclusive, to the point where they avoid engaging with people or things that they formerly found enjoyable. Recognizing an eating problem in its early stages might be helpful in guiding the individual in question to get the treatment they need in order to make a full recovery.
Types of Eating Disorders
Anorexia nervosa, bulimia nervosa, binge-eating disorder, pica, rumination disorder, and avoidant/restrictive food intake disorder are the six eating disorders that are now recognized in the DSM-5. Treatments are often successful for persons battling with any eating disorder, despite the fact that each has its own distinct set of symptoms.
Anorexia is characterized by a persistent phobia of gaining weight or of the sensation of being overweight, which leads a person to restrict their food intake to the extent that prevents them from maintaining healthy body weight. They might have an inaccurate view of their own physique and fail to recognize the severity of their underweight condition as a result.
It is estimated that women are up to ten times more often than males to suffer from anorexia. Although it often occurs in youth or early adulthood, the second surge in incidence seems to happen beyond the age of 40.
Anorexia develops owing to various factors, including genetics, life situations such as childhood trauma, and societal beauty norms, all of which may play a part in its development but are never totally responsible for it. The basis for the development of a condition may also be laid through social comparison, particularly during college years. People who have anorexia often battle with anxiety, perfectionism, and obsessive-compulsive tendencies. They may also have a strong desire for control or demonstrate rigid and inflexible thinking.
These characteristics become evident in how individuals who struggle with anorexia eat meals. They may only eat at certain times of the day or with certain types of utensils. They could fixate on the calorie counts and serving sizes of the foods they eat. They could eat by themselves or continually come up with reasons why they can’t eat. They could cut down on their usage to the point that they have digestive issues, electrolyte imbalances, hair loss, brittle bones, dizziness, or even passing out. Both the condition itself and suicide are potential causes of death for those who have anorexia. It is the mental disease with the highest mortality rate.
However, rehabilitation is attainable via the collaborative effort of a group. The treatment entails the participation of a nutritionist in addition to a physician and a psychotherapist. Effective therapies for eating disorders may be received outside of an inpatient hospital environment. These include cognitive behavioral therapy, as well as an adaptation of CBT, termed enhanced cognitive behavioral therapy (CBT-E). Family-based treatment is another option. Recovery is a process that involves continual effort, yet moving forward in the process may enable people to construct a life that is joyful and satisfying.
A person is said to have bulimia if they binge eat on a regular basis and then try to control their weight by purging, using laxatives or diuretics, restricting their food intake, or engaging in strenuous physical activity. Binge eating is characterized by both a lack of self-control and the consumption of a considerable quantity of food in a short length of time.
When this pattern continues at least once a week for a minimum of three months, a diagnosis of the disease may be made. The onset of bulimia often occurs around adolescence. Risk factors include physical or sexual abuse in childhood, traumatic experiences, adolescent obesity, early puberty, and mental health issues such as poor self-esteem, anxiety, and despair. There is also a biological aspect to consider here.
Bulimia is often intertwined with shame and secrecy, which is why the disorder is sometimes called the “secretive syndrome.” People who struggle with the eating disorder bulimia may have normal or even excessively high body weight. The disease may cause a person to feel anxious and ashamed, and the act of purging, in particular, can have the sensation of being an addictive behavior that the individual feels is “unwanted,” “out of control,” or “disgusting.” People may be dissuaded from obtaining therapy due to their feelings of shame.
However, therapy is essential since, in addition to mental anguish, bulimia may lead to a variety of physical issues. Bulimics risk being dehydrated, losing electrolytes, having their teeth enamel worn away, and experiencing problems with their digestive system.
A dietitian, a primary care physician, and a mental health expert are all members of the treatment team for bulimia. This allows for both medical and psychological care to be administered to the patient. Antidepressant medication is occasionally provided to patients in addition to cognitive behavioral therapy and family-based treatment as standard treatment methods for patients who also suffer from co-occurring mental health issues.
A binge-eating disorder is characterized by recurrent episodes of binge eating, which include the involuntary ingestion of an excessive quantity of food in a relatively short period of time. Eating too much food in a short period of time, eating to the point of discomfort, eating a lot while not feeling hungry, eating a lot when eating alone out of shame, and then feeling guilty or disgusted with oneself afterward are all examples of binges.
When binges occur once a week for at least three months, when purges or laxatives don’t follow them as they are in the case of bulimia, and when the experience leads to unhappiness in the person’s life, a diagnosis of compulsive overeating disorder may be made. Although being overweight is common among those who struggle with binge eating disorders, it is not universal.
The United States has the highest prevalence rate of binge-eating disorder of any country in the world. A significant number of individuals also experience a progression from one eating disorder to another throughout the course of their lives, for example, battling with anorexia at one point in time and then binge eating at another.
During a binge, an individual may have the sensation of feeling out of control or even dissociating themselves from the event. As a consequence of this, they may serve as a release, giving the individual the capacity to avoid experiencing or feeling terrible things in their life. People who suffer from binge eating disorder often battle powerful feelings of guilt and self-criticism related to the condition.
The treatment for binge eating disorder involves treating the underlying issues, such as low self-esteem, perfectionism, depression, and negative body image, as well as building good coping skills. Although cognitive-behavioral therapy is the most common kind of treatment, many other forms of therapy may also be beneficial.
Two Exciting New Treatments for Binge-Eating Disorder
- People who suffer from the binge-eating disorder may find that participating in behavioral weight loss treatment assists them in overcoming their problem and achieving their weight reduction goals.
- The combination of naltrexone and bupropion could also be useful for those who struggle with binge-eating disorder.
- According to the findings of a recent research, the two medicines working together may show to be even more successful than using each one alone.
A substantial amount of anguish and distress may be brought on by a binge eating disorder. It is a scary experience to be ruled by one’s appetite for food, and the lack of control may cause a person to feel shame, remorse, and contempt for themselves. The adverse health effects, which may include diabetes, high cholesterol, and excessive weight gain, may be quite problematic.
Additionally, the disease makes therapy difficult to do. The cornerstones of psychotherapy treatment are known as cognitive behavioral therapy (CBT) and interpersonal therapy (IT). The Food and Drug Administration has blessed the use of just one medicine to treat binge-eating disorder: Vyvanse. However, since this drug is a stimulant, it has the potential for misuse and has the ability to speed up the heart rate and elevate blood pressure. Topiramate may produce drowsiness and has the potential to have adverse cognitive effects. However, it is beneficial for reducing binge eating and promoting weight reduction. Although selective serotonin reuptake inhibitors, sometimes known as SSRIs, may help minimize binge eating, they do not in and of themselves encourage weight reduction. Many individuals continue to suffer despite accessible remedies.
A New Study
Behavioral weight loss therapy (BWL) and naltrexone-bupropion are two treatments that are well-established for the treatment of obesity but are not well-studied in people who suffer from binge-eating disorder. Researchers decided to study these two treatments in order to learn more about how to treat binge-eating disorders.
BWL is a behavioral treatment that does not need higher-level training to acquire, that has been thoroughly investigated for weight reduction, and that is beneficial in assisting those who are overweight in their efforts to reduce weight. Studies have demonstrated that this treatment may decrease binge eating for those who suffer from binge-eating disorders while also aiding weight reduction. Some studies have achieved remission rates of up to 74 percent for binge eating and 5.1 percent for weight loss.
BWL is a manualized program, and its modules, which include goal-setting, monitoring of food intake and exercise, stimulus management to eliminate triggers, and problem-solving, are basic. It recommends a modest reduction in caloric intake to 1,500 calories per day, an improvement in the quality of diet (including a decrease in fat), and the performance of 30 minutes of physical exercise five times a week.
There is a combination tablet called naltrexone-bupropion that the FDA has licensed for the treatment of obesity. Studies have shown that taking this medication may lead to mean weight decreases of up to 6 kilograms (27 lbs). Greater weight reduction is one of the advantages of using this medicine rather than some other weight loss tablets (compared to orlistat and liraglutide). The medication can’t be used simultaneously as opiate painkillers, and there’s a small chance that it might cause an increase in blood pressure, heart rate, seizures, or liver inflammation. These are the drawbacks. There is also a “black box” warning about an increased risk of individuals taking their own lives; some persons report despair as a side effect. The combination of these two drugs has the effect of suppressing the patient’s appetite by enhancing the activity of the neurons that produce pro-opiomelanocortin.
In the study, 136 people who suffered from binge-eating disorder (80 percent women, mean age 47, and mean body mass index 37) were randomly assigned to one of four groups for the duration of the study: placebo, naltrexone-bupropion, BWL plus placebo, and BWL plus naltrexone-bupropion (32 mg/day of naltrexone and 360 mg/day of bupropion, both sustained-release).
The outcomes regarding binge eating showed encouraging results for both treatments: 31 percent of people stopped binge eating when they took medication, 37 percent stopped when they took BWL plus placebo, 57 percent of people stopped when they got both active treatments, and only 18 percent stopped when they took placebo alone.
Both the drug and the treatment were successful in causing the patient to shed extra pounds. Whereas only 12 percent of participants in the placebo group lost more than 5 percent of their body weight, 19 percent of participants in the mediation alone group, 31 percent of participants in the BWL and placebo group, and 38 percent of participants who received both active treatments lost more than 5 percent of their body weight.
According to the results of statistical testing, medicine was substantially more successful than the placebo in putting an end to binge eating, and behavioral work therapy was significantly more effective than not doing BWL in putting an end to binge eating as well as losing weight.
Despite the fact that both of these treatments show promise, particularly BWL (which showed statistically significant effects on both body weight and binge eating in this study), there are a few warnings that should be heeded by healthcare providers who are considering implementing either one or both of these treatments with their patients.
In prior research on obesity, it was shown that the long-term dropout rates for the medicine naltrexone-bupropion were significant, reaching approximately 50 percent after one year of therapy. This is concerning. This is also true for the other drugs for weight reduction, some of which may not offer patients a loss of weight that is maintained over time. It is also not well understood what the success rates are for BWL over the long run.
People who suffer from the binge-eating disorder are at increased risk of experiencing severe rebound weight gain after losing weight. This is because binge eating causes rapid weight regain, and those who engage in this behavior risk being trapped in an unhealthy cycle of yo-yo dieting. The trial duration was just sixteen weeks, and it is not yet known what the long-term effects of either therapy will be for the participants.
On the bright side, these therapies could provide something novel that the industry has been begging for a very long time. Binge eating disorder is often treated in eating disorder programs, and these programs typically do not promote weight reduction as a primary treatment objective. Although removing the possibility of weight loss from the equation might assist individuals in ending binge eating, this strategy might not be the best choice for those who, for example, face significant health risks associated with larger body sizes. Both BLW and naltrexone-bupropion, whether used alone or in combination, have the potential to assist individuals in cutting down on binge eating while also facilitating weight loss.
Both behavioral weight loss therapy and naltrexone-bupropion might be regarded as viable treatment options for those who are attempting to recover from binge-eating disorder, which is encouraging news. Both of these treatments are aimed at reducing excess weight.
Pica is diagnosed when a person routinely consumes items that are not intended for human consumption. This might include things like paper, soap, fabric, paint chips, crayons, mud, or ice; all of these are examples of meals that have little nutritional value and may be hazardous to digest.
The disorder is diagnosed when the behavior has been present for at least one month, it is not compatible with the child’s age or developmental stage, the practice is not typical of cultural or social norms, and it does not occur within the context of another condition order, such as intellectual disability or autism. Pica is a condition that often isn’t recognized until after the age of two, and it mostly impacts youngsters as well as pregnant women.
Why would anybody consume things that aren’t food? Some persons who have pica report that the taste, texture, or fragrance are pleasant to them. Some people believe that consuming some nonfoods might help relieve tension and anxiety. Some people may have obsessive behaviours as a result of this conduct. In addition, there are those who, for religious reasons, cultural reasons, or medical reasons, ingest things like clay (although these cultural norms would rule out a diagnosis.) Malnutrition, stress, abuse, and other mental health issue are all variables that might put a person at risk for developing the illness.
It is not always possible for doctors to determine whether or not a patient is ingesting nonfoods. Patients often do not disclose this information to their physicians either out of embarrassment or because they do not think it is uncommon. Pica, on the other hand, may have serious repercussions, such as choking, poisoning, and nutritional inadequacies; thus, it is essential to seek therapy for the condition. The treatment for this condition may entail both medical interventions to treat issues and psychotherapy to help comprehend and encourage good eating.
People are said to be ruminating when they regurgitate their meals after each meal on a regular basis. After then, they either chew it up and swallow it or spit it out. There is no feeling of nausea or vomiting prior to regurgitation, and the gag reflex is not triggered.
When symptoms of the illness have been present for at least one month, and testing reveals that they are not caused by another medical ailment, eating disorder, or mental health issue, a diagnosis of the disease may be made. The individual may have a decrease in weight, remain at the same weight, or demonstrate developmental difficulties.
Rumination is a condition that most often affects infants and children, although it may also manifest in adults. For infants and young children, worry and stress are risk factors; for adults, anxiety and depression are risk factors.
Some patients have characterized the syndrome as being habitual or as being beyond their ability to control; hence, treatment may centre on breaking and reversing these behaviors.
Avoidant/Restrictive Food Intake Disorder
A person is said to have avoidant/restrictive food intake disorder (ARFID) if they don’t consume enough food to meet their energy or nutritional requirements. A person who has ARFID may not eat because they fear the repercussions of eating, avoid eating because of the sensory qualities of foods such as their texture or smell, or simply not show any interest in eating at all. As a consequence, the individual may have a loss of weight, nutritional inadequacies, and developmental issues.
The condition most often manifests itself during infancy or childhood. When avoidance is not explained by a lack of food availability or cultural practice, it is labeled as a selective eating disorder. It is essential to rule out the possibility of physical ailments, eating disorders, and mental health difficulties. In addition to gastrointestinal issues, anxiety, obsessive-compulsive disorder (OCD), and autism are also risk factors for ARFID.
The distinction between ARFID and picky eating is one that many people have trouble understanding. When a person’s caloric or nutritional requirements are not met, picky eating approaches the threshold of becoming an eating disorder. They could not be able to acquire weight, their current weight might not be acceptable for their height, or they might rely on supplements. A person may have a disorder if the issue starts to affect their day-to-day functioning to the point that it becomes problematic.
ARFID is not the same as anorexia in another critical respect: the aversion to eating that is characteristic of ARFID is not motivated by concerns over one’s body image or the fear of gaining weight, as is the situation with anorexia.
A nutritionist is the best person to treat ARFID. However, other professionals, including pediatricians, gastroenterologists, and psychologists, may assist in figuring out the cause of the disease and devising treatment strategies.
Causes of Eating Disorders
No one factor causes eating disorders in isolation. It is not yet known why habits related to eating that seem to be choices evolve into diseases for some persons but not for others.
All forms of eating disorders have the common characteristics of an unhealthy connection with food and a heightened awareness of one’s own emotional vulnerability. In most cases, the first signs of an eating problem are subtle, such as an individual eating slightly more or slightly less food than average. The desire to consume more or consume less food gets more powerful with time, to the point that it may destroy a person’s whole life.
The field of biology also contributes. The management of food intake and the control of appetite is a very complicated process that involves a number of hormones in the brain and the body that indicate when someone is hungry or when they have had enough to eat. Additionally, there is evidence that points to hereditary causes for eating problems.
It is believed that culture also plays a considerable effect since it places a substantial amount of pressure on individuals, particularly women, to conform to an ideal of beauty that is mainly defined by weight.
Other factors come into play, such as the fact that the conditions may be brought on by factors such as stress, social problems, loneliness, despair, trauma, or even the act of dieting itself.
Types of treatment for eating disorders
Outpatient treatment for eating disorders often involves participation in a number of different types of therapy. The most effective therapies now available are known as Cognitive Behavioral Therapy (CBT), Enhanced Cognitive Behavior Therapy (ECBT), and Family-Based Treatment. Other types of therapy, such as Dialectical Behavior Therapy, Acceptance and Commitment Therapy, or Psychodynamic Therapy, may also be practiced by clinicians.
Enhanced Cognitive Behavioral Therapy
Cognitive behavioral therapy and enhanced cognitive behavioral therapy are two approaches that are often used in the treatment of eating problems. CBT-E is a treatment that was developed exclusively for eating issues. It addresses the ideas that keep the disorder going and guides the client to decide for themselves to maintain a healthy weight. It is an individualized therapy strategy that addresses the thoughts that keep the condition going.
Additionally, key transformation obstacles, such as perfectionism, poor self-esteem, and relational difficulties, are tackled head-on by cognitive behavioral therapy for eating disorders. According to what has been said by a few researchers, “the psychopathology of an eating disorder may be compared to a house of cards,” and the goal of treatment is to “find and remove the crucial cards that are sustaining the eating disorder, ultimately bringing down the whole house.”
CBT-E effectively treats all forms of eating disorders, including anorexia, bulimia, and binge-eating disorder. There are variants designed specifically for people who are older or younger, as well as for inpatient and outpatient treatment regimens. In most cases, treatment consists of one session lasting fifty minutes once every week for twenty weeks. People who are dangerously underweight may need therapy that is more intensive and lasts for a longer amount of time, such as forty weeks. This treatment may focus on regaining weight and treating troublesome cognitive patterns.
It has been shown via clinical studies that CBT-E is an effective treatment for eating disorders; however, further investigation is required to discover whether or not it is consistently more successful than cognitive behavioral therapy.
One of the most effective treatments for teenagers struggling with eating disorders is called Family-Based Treatment (FBT). It is also known as the Maudsley technique, which got its name from the British hospital in the 1970s, which was the origin of its development.
The strategy includes the participation of the whole family. It gives parents the tools they need to help their children eat and go back to a healthy weight. During this phase of the process, the parents take charge of the kid’s eating habits and then gradually give those responsibilities back to the youngster.
Studies have shown that family-based treatment is a successful method for assisting teenagers on their path to recovery. However, parents need to be aware that it is a significant commitment in terms of both time and energy and that it is better suited for certain families than for others.
Do any medications treat eating disorders?
It is possible to get a prescription for medication to treat related symptoms, such as anxiety or depression. However, there is not a single medication that has been authorized to treat eating disorders at this time.
It is well known that some drugs lead patients to put on weight; however, patients will not consent to put on weight until the underlying psychological issues that are driving the condition are addressed. Participants in clinical trials are another factor that makes medication discovery more difficult.
Someone I love has an eating disorder. How can I help?
Although the choice to seek therapy may seem incredibly obvious to a loved one, making that choice may be challenging and stressful for the one who is having difficulties. Doing a study on eating disorders may be helpful in better understanding the issue and having more empathy for those who struggle with it.
It may take some time to guide someone who struggles with an eating problem toward the conclusion that they should get treatment for their condition. It is possible that it will entail questioning the individual about their thoughts and emotions, assisting them in admitting that they do have a problem, and thinking on objectives for their future that may make therapy seem essential and worthwhile.
When discussing treatment options, it may be helpful to exchange information with one another. One such resource is a list of mental health doctors in the region that accept their insurance, and one can also volunteer to accompany them to one of their appointments. You should strongly encourage the individual to seek both psychological counseling and medical attention. Later on, you should check in with them to make sure that they are sticking to the strategy that you outlined before.
How do you help someone who refuses treatment?
People may choose not to get treatment for a variety of reasons, including the fact that they do not feel they are afflicted with a disease or the fact that they find the prospect of addressing the sickness excessively stressful. It may be extremely beneficial to maintain support for someone and urge them to seek therapy throughout the course of time. It can also be quite helpful to provide tools that make the subsequent stages seem less difficult.
Parents who are really concerned about their kid might consider, in addition to offering love and support, making the acquisition of some financial resources, such as a vehicle or the payment of college tuition, contingent upon the child receiving therapy. When it comes to children under the age of 18, their parents have the authority to order treatment or admit them to the hospital.
For those above the age of 18, legal procedures such as guardianships and conservatorships may be pursued in order to exercise control over their medical treatment. Because they are coping with the condition that might result in death, loved ones may believe that it is essential for them to turn to these extreme measures, despite the fact that doing so is the last option.
Parenting a Child with an Eating Disorder
It may be quite distressing to see a youngster who is struggling to overcome the effects of an eating problem. It is important for parents to remember that they are not to blame for their kid’s disease, but they may take action to assist their child’s recovery and support them.
Actions must be performed differently depending on where the process progresses. These stages may involve detecting the indicators of a condition, acquiring knowledge about the illness, having a conversation about it with the kid, and encouraging them to seek treatment.
The Recovery Process
Getting well after struggling with an eating problem is a huge step forward, but it’s also a journey that never ends. It is typical for there to be both forward movement and temporary setbacks. The logistics of rehabilitation will look extremely different for each individual, such as in relation to the types of eating habits and treatment regimens that are devised. Clinical treatment and emotional and social support from others will significantly assist in achieving a full recovery, even if it takes many weeks, months, or even years.
How many people recover from eating disorders?
A significant number of individuals are able to conquer their eating problems and go on to enjoy happy healthy lives. But even when there are less people there, the chaos does not get better.
The total recovery rate has been shown to be approximately fifty percent in previous studies; however, studies that followed participants for a longer length of time indicated that two-thirds of women with anorexia and bulimia totally recovered 22 years after the first diagnosis. After the first 10 years, around one-third of women suffering from anorexia had recovered, whereas two-thirds of women suffering from bulimia had recovered. However, by the end of the second decade, around two-thirds of female patients had fully recovered from anorexia.
What leads to a successful recovery?
The first step toward recovery is treating the disease in all of its manifestations. On a physiological level, the body requires time to recover from the damage caused by the condition. This may be accomplished in a number of ways, including maintaining a healthy weight and normal hormone and electrolyte levels. The individual has to adopt healthy behavior patterns regarding food and how they evaluate their looks. This may be done via behavioral modification. The person may address, from a psychological standpoint, the factors that contribute to the development of the condition, such as their body image, perfectionism, anxiety, or past traumatic experiences.
A solid support network is an additional important factor to consider. It is common for loved ones to play an essential role in successful recovery by providing encouragement to the sufferer to eat, continue treatment, speak through difficulties, and work toward achieving their broader objectives.
How can I help a loved one during the recovery process?
The essential thing you can do to assist a person who is struggling with an eating problem is to maintain your love and support for that individual throughout time. It may be challenging to sustain energy and support for such an extended amount of time—throughout times of disorder, treatment, relapse, and recovery—which is why loved ones need to make sure they give themselves time to focus on their own health.
In addition to offering them love and support, it might be beneficial to encourage them with details, such as eating the next meal or attending the next treatment session. It may also be useful to reflect on the benefits of therapy and recovery in terms of the person’s life objectives, which are what encourage them to continue constructing their future, such as securing a dream career, finding a relationship, or just living without worry.