Is Anorexia really a disease?

[Epok]

With regards to the responsibility argument, that seems to make some sense until you realise that the treatment for many of these disorders involves taking control and responsibility. So admittig you have one of these disorders and seeking treatment is the opposite of abdicating responsibility.

I think that is a good point because it seems to concur with my statement that it is a conscious action/thought that starts it in the first place.

 

[Epok]

Why do you not hold schizophrenics to the same standard, they are choose how to act after all. They should just ignore the voices.

I have a good reason to believe that schizophrenics cannot help but hear the voices. My friend even says that she understands that the voices are delusions but there are some instances where the voices become overwhelming. I just haven't seen enough evidence that shows that anorexia is as bad as schizophrenia. A lot of the things that have influenced my opinion on anorexia is the ridiculous excuses that I have heard people claim and, I admit, some of the ridiculous things I have heard on Dr. (I don't even know if he is a real doctor) Phil.

 

[Epok]

And the fact that the climber can quit any time he wants, while an anorectic has to spend months or years digging herself out of her situation doesn't mean anything to you? Neither disorders nor alcoholism or drug addiction are a simple matter of "just quitting", and anyone who says otherwise is, quite frankly, deluding himself. I have plenty friends with mental problems and I volunteer at a street magazine publishing house. I know what I'm talking about.

I used to drink like a fish til I crawled like a rat. I have been called an alcoholic even though I don't agree with AA's definition of an alcoholic. I did get myself to the point where I was normal again and I did it without AA or a 12-step program. It was a matter of just quitting,well, I never quit cold turkey but I did quit getting so drunk that I made a fool of myself. I realized that what I was doing was selfish and I had nobody to blame but myself. Forget genetics and all that BS. I think everyone is capable of becoming addicted to something if they lose their willpower. That is why I have my opinions about anorexia. I feel that it is similar. But because of this thread I do think that there may be some cases where someone is severely delusional to the point where they actually can't help it. But I still think that in a lot of cases people act this way to get attention.

 

[Sunray Breaker]

I wasn't aware that people with leukaemia, diabetes, asthma and pneumonia were capable of stopping their suffering at any given moment...

Regardless of what the experts say about anorexia or alcoholism I have to disagree with the way they treat these issues...In a world where nearly every woman complains about looking fat (when they know damn well they are not) It doesn't at all suprize me the bizarre lengths at which they'd go to to get that way. If you ask me, it's a societal issue and not a health one. If anorexia is a disease, what then is the physical cause?

Could not also be said that women who stretch their necks, modify their bodies, pierce and tattoo, crush their own feet, also have a disease? It really is the same sort of psychological process (I could be wrong), but because it's socially acceptable to a certain point, it's not considered a disease?

I'm also curious to see how many psychologists have studied the amount of women that aspire to be models, read cosmo (religiously), watch America's Next Top Model, in comparison with how many of those women suffer from some sort of eating disorder.

Granted we couldn't fall back on the (it's all societies fault) scapegoat, but there is clearly an effect that it has had in the rise of eating disorders...

After all...this "disease" doesn't exist in Africa (where in some places it's considered more sexually appealing to have MORE body fat.)

The same argument could likely be made when comparing a fast-rising, media based, infotainment age and it's connections with ADHD.

Sorry, but I have to agree with the OP. I've been skeptical of psychology regarding some of it's findings. Most of which I must admit are valid and have a lot of evidence to support it. But as far as how it handles severe depression, anorexia, bolemia, cutting, bi polar disorder, ADD, etc it seems to have a bad track record.

They are too quick to medicate a lot of these poor people who, half the time...just need someone to talk to.

I've only been to therapy twice, because I was sad about breaking up with my girlfriend and needed to get some things off my chest. After the first session this therapist was writing me a prescription for Prozac. I was insulted.

I refused to accept it, went home, smoked a little bit of ganja and wrote a song about it.

Two weeks later I was fine. I can only imagine how differently that would have effected me on meds.

Granted, in extreme cases of any of the above mentioned circumstances, medication is sometimes the ONLY option and some people do prefer it.

But it seems that medication should be considered a last resort when dealing with psychological issues of any sort, as a lot of eccentric people (perfectly capable of taking care of themselves) can, under the right amount of pressure, appear to be psychologically disturbed.

Christ, it would appear that more than half the women I've ever met in my life (if not more) are on some sort of medication and have been diagnosed since they we're fifteen. Now they can't function without there medications...Or is it they just don't want to?

I wonder why therapists seem so quick to abandon creative outlets and forms of positive expression as ways to treat such illnesses (I could be drawing an ignorant conclusion here, but I've rarely heard a psychologist suggest therapeutic methods of artistic expression as a solution to behavioral issues).

I may sound cold about this issue, and frankly I am. I think giving sympathy to people who beg for it, just encourages more begging (not to mention more people who want attention and need a way to get it.)

I can speak from personal experience. Some of my closest friends are currently medicated or recovering from medication.

I know VERY personally 3 schizophrenics, two on medication (both heavy drug users and alcoholics, 1 who is not (and has a great job and a stable life and has taught himself to control his episodes through focusing on distractions).

My roomate is bi-polar, has been medicated all the way up to age 20 (she's 23 now) has lived 3 years without medication...In that time she's managed to move out of her parents house, find stable friends and roomates and now manages a Good Will.

My best Friend Stacy of 10 years. Diagnosed as bi-polar, her parents have had her on medication ever since middle school, she currently averages 15-17 medications per day, is an emotional wreck, still lives with her parents at the age of 26, has wrecked three vehicles, 2 DUI's and lord knows how many suicide attempts.

I treat these people as I would anyone else and they are all very close to me and value my bluntness....

So lets not forget (regardless of how much this strays from the OP) how important it is to not placate to people's self inflicted harm as it can often encourage that self harm (as it would seem to be the case in my experiences).

To call alcoholism a disease (in my opinion) just eliminates any and all responsibility the addicted person (at least in their own mind) has to correct it....

I could be wrong though, just my uneducated, two cents

 

[Dancing David]

Cool, so what about the test for schizophrenia?

I bounce like a pinball because I respond to your bouncing, okay.

I would never say anything is defintive, but you still haven't said what the test for schizophernia is nor provided evidence for your statement.

And now some blind noob on a bulletin board wants to question my professionalsim at a former job, do you read mind and fortunes as well? The fact that you would even mention it means that you can't muster an argument to support your contention that anorexia nervose is based upon "the pity factor with which sufferers seem to love, and the fact that you are not born with it or that you are consciously hurting yourself for selfish reasons".

So considering you haven't presented a reason for anorexics to do what they do, nor devise a test that would determine that, you now attack my former professionalsim.

Figures, can't do your homework, pretend you were 'just looking for answers' and then spin.

Uh-huh.

 

[Epok]

Cool, so what about the test for schizophrenia?

I bounce like a pinball because I respond to your bouncing, okay.

I would never say anything is defintive, but you still haven't said what the test for schizophernia is nor provided evidence for your statement.

And now some blind noob on a bulletin board wants to question my professionalsim at a former job, do you read mind and fortunes as well? The fact that you would even mention it means that you can't muster an argument to support your contention that anorexia nervose is based upon "the pity factor with which sufferers seem to love, and the fact that you are not born with it or that you are consciously hurting yourself for selfish reasons".

So considering you haven't presented a reason for anorexics to do what they do, nor devise a test that would determine that, you now attack my former professionalsim.

Figures, can't do your homework, pretend you were 'just looking for answers' and then spin.

Uh-huh.

First off, I question your professionalism because of your spelling and your attitude. You couldn't even get the quoting system right and I had to edit my reply so that it didn't look like I was trying to use your words. Your spelling isn't that good and I'm guessing its because you do not proof-read before your Submit Reply. You fly off the handle and start insulting me thinking that it proves your point. Your links were not conclusive. And similar to what Sunray Breaker said (which I agree with everything he said) there is a lot of Woo going around in psychology and not enough critical thinking going on.

Now as for what I said about schizophrenia being testable. I finally had a chance to talk to my friend and she said they used a PET scan and a blood test to check her DNA. I don't have any links to it because I have already said I have a friggin' 5-month-old bobcat I gotta feed and I don't have time to post a bunch of links with inconclusive evidence as you have done. But I'm not mad. I got better info from everyone else than I did from someone who claims to have worked in the mental health profession (or are you like the doctor in the novel Choke who thought she was a doctor?).

I appreciate the people who gave practical information and didn't resort to pettyness.

 

[paximperium]

I could be wrong though, just my uneducated, two cents

Yes you are.

 

[paximperium]

First off, I question your professionalism because of your spelling and your attitude. You couldn't even get the quoting system right and I had to edit my reply so that it didn't look like I was trying to use your words. Your spelling isn't that good and I'm guessing its because you do not proof-read before your Submit Reply. You fly off the handle and start insulting me thinking that it proves your point. Your links were not conclusive. And similar to what Sunray Breaker said (which I agree with everything he said) there is a lot of Woo going around in psychology and not enough critical thinking going on.

Now as for what I said about schizophrenia being testable. I finally had a chance to talk to my friend and she said they used a PET scan and a blood test to check her DNA. I don't have any links to it because I have already said I have a friggin' 5-month-old bobcat I gotta feed and I don't have time to post a bunch of links with inconclusive evidence as you have done. But I'm not mad. I got better info from everyone else than I did from someone who claims to have worked in the mental health profession (or are you like the doctor in the novel Choke who thought she was a doctor?).

I appreciate the people who gave practical information and didn't resort to pettyness.

Sorry but that was just a sad sad post. It was actually petty. I suggest you reread it and look at the amount of logical fallacies and mud flinging you just did.

Beyond the insulting tone of Dancing David, which I will not excuse him for (although I understand the passion of someone who works against the bigotry of the public directed at the mentally ill) I have yet to see anything that he has written to be wrong. In fact he has presented evidence which you are lacking.

He has not and never claimed to be a Doctor so you insinuation is not warranted. Your dismissal of the evidence is also not warranted. You say "inconclusive" but I doubt you actually read any of it or frankly I doubt you even understand it. You are ignorant of this subject. Completely and utterly so and your "there is a lot of woo in psychology" is a beyond retarded ad hominem. You know this how? What does Psychiatry say about this? What about the Neuropsychiatry and neurobiology of these people? Or did someone say something you heard?

There is NO test for schizophrenia except via similar criteria used on Anorexia Nervosa and Alcoholism. A PET Scan and DNA test are not part of any psychiatric diagnoses. Your friend was likely involved in a study. Psychiatry and psychology is an evolving field. The criterias changes and we understand so much of how the brain works.

This defensive whiny play is not exactly very "skeptical" or even open minded. You can either learn something or close your mind. Your choice.

 

[blutoski]

Anorexics and alcoholics don't condition themselves to become that way because of choices they make.

I sort of came late to the thread, but I think paximperium made the most relevant points. AN is a disorder because it means the pt cannot function normally. This type of diagnosis is neutral toward pt accountability.

On an individual basis, the treatment will vary depending on what the therapist gets out of the structured interview. Some pt have more control over their situation than others.

eg: for some, this is akin to body modification, simply part of their social norms or competition - they have a accurate perception of their physical condition and associated risk but are willing to accept the consequences

However, for others, it does appear to be caused by distorted perception of their physical condition and do not believe they are at risk



In either case, the purpose of classification in DSM IV TR - like all disorders classified therein - is to anchor the condition's features so that research into treatment is consistent.

Classification in the DSM is neither a condemnation nor an excuse.

 

[paximperium]

I sort of came late to the thread, but I think paximperium made the most relevant points. AN is a disorder because it means the pt cannot function normally. This type of diagnosis is neutral toward pt accountability.

On an individual basis, the treatment will vary depending on what the therapist gets out of the structured interview. Some pt have more control over their situation than others.

eg: for some, this is akin to body modification, simply part of their social norms or competition - they have a accurate perception of their physical condition and associated risk but are willing to accept the consequences

However, for others, it does appear to be caused by distorted perception of their physical condition and do not believe they are at risk. A Disorder is a spectrum.



In either case, the purpose of classification in DSM IV TR - like all disorders classified therein - is to anchor the condition's features so that research into treatment is consistent.

Classification in the DSM is neither a condemnation nor an excuse.

Exactly. There are many who are able to be selectively anorexic and even alcoholic but are totally functional and are able to control themselves. I may not condone it but it is not an issue. Damn, my granddad sat around every night and drunk himself to a stupor and then went to work, hung in the weekends and never bothered anyone. When told his liver was starting to go, he stopped.

These are not the ill sick people that I care about and which the OP and sunray breaker seem unable to differentiate from. Many alcoholics can't stop and that is the disorder. That is the problem.

 

[Dancing David]

First off, I question your professionalism because of your spelling and your attitude. You couldn't even get the quoting system right and I had to edit my reply so that it didn't look like I was trying to use your words. Your spelling isn't that good and I'm guessing its because you do not proof-read before your Submit Reply. You fly off the handle and start insulting me thinking that it proves your point.

No I was insulting, I expect that to decrease my credibility.
As was the tone of your OP, insulting.

Your links were not conclusive.

Ah, yes I claimed they were conclusive, sure. They indicate a possible biological vulnerability.

And similar to what Sunray Breaker said (which I agree with everything he said) there is a lot of Woo going around in psychology and not enough critical thinking going on.

Because you talk to people who are not professionals, or because you watch TV, there is a lot of woo everywhere. I think Jeff Corey is very critical, as are many psychologists.

So support your claims that it is self pity that drives anorexia nervosa.

Now as for what I said about schizophrenia being testable. I finally had a chance to talk to my friend and she said they used a PET scan and a blood test to check her DNA.

And how did they decide from that?

You have an anecdote so far, I am asking because I am truly curious. I haven't heard about this, so I am interested. It would be a big deal

I don't have any links to it because I have already said I have a friggin' 5-month-old bobcat I gotta feed and I don't have time to post a bunch of links with inconclusive evidence as you have done.

Yeah and I was typing in a lab full of second graders while I took my break.

And again I asked you to support your opinion. You can take your time, i will be here.

But I'm not mad. I got better info from everyone else than I did from someone who claims to have worked in the mental health profession (or are you like the doctor in the novel Choke who thought she was a doctor?).

And the evidence supporting your claims is?
The test for schizophrenia works , how??

As I said, there are no definitives.

I appreciate the people who gave practical information and didn't resort to pettyness.

I still ask you to support your theory of anorexia. Take your time. I was rude and insulting which is not helpful, but you have an anecdote and nothing else.

Perhaps in some other thread.

And again your theory of

but I don't have a good reason to believe it for a few reasons: its not like testing for cancer or schizophrenia, people say "its a disease" seemingly as an excuse to not own up to their own actions (similar to the way alcoholics and addicts do), the pity factor with which sufferers seem to love, and the fact that you are not born with it or that you are consciously hurting yourself for selfish reasons (again the same way alcoholics, addicts and even cutters do).

Is unsupported.

I aopologise for not spell checking on my break, it is a bad habit.

Perhaps another day we shall talk again, when you can support your opinions.

 

[Dancing David]

I think that is a good point because it seems to concur with my statement that it is a conscious action/thought that starts it in the first place.

And intrusive thoughts in OCD are... consciousthoughts, and the compulsions are often deliberate.

So they start with something that is behavioral or biological?

 

[blutoski]

Exactly. There are many who are able to be selectively anorexic and even alcoholic but are totally functional and are able to control themselves. I may not condone it but it is not an issue. Damn, my granddad sat around every night and drunk himself to a stupor and then went to work, hung in the weekends and never bothered anyone. When told his liver was starting to go, he stopped.

These are not the ill sick people that I care about and which the OP and sunray breaker seem unable to differentiate from. Many alcoholics can't stop and that is the disorder. That is the problem.

My wife and I have both worked in the eating disorder clinic at SPH, and it's a real mixed bag of patient insight. The social dynamics are hard to watch. Sometimes it's very obvious what's going on. eg: punishing a parent, regressing to pre-pubescence. Sometimes, it's clear the pt is not at all in control. Every case depressed me.

 

[Dancing David]

Beyond the insulting tone of Dancing David, which I will not excuse him for (although I understand the passion of someone who works against the bigotry of the public directed at the mentally ill) I have yet to see anything that he has written to be wrong. In fact he has presented evidence which you are lacking.

I was insulting and I am often wrong.
You on the other hand seem to be very cautious in what you post.

"there is a lot of woo in psychology" how?

Well I think the issue there is that there are levels of psychology, there is the old terrible psychology that like a zombie just won't die, we have had people defend all sorts of neo-Freudian and Freudian crud on the board. Then there is the lameltable 'pop' pyschology which seems to thrive in the media, Most horrible are 'expert psychologists' on the news shows. But there are so many pop psych books written for so many reasons.

I even got sucked in by the whole EMDR thing.

So there is a lot of woo in psychology, just like there is a lot of woo about quantum physics, alternative medicine and the like.

I have even seen therapists I respected talk about woo like 'watching sexualized TV cause children to mature faster', it is harder to not laugh at that than when you hear about the UFO tri[ a client took.

 

[Dancing David]

My wife and I have both worked in the eating disorder clinic at SPH, and it's a real mixed bag of patient insight. The social dynamics are hard to watch. Sometimes it's very obvious what's going on. eg: punishing a parent, regressing to pre-pubescence. Sometimes, it's clear the pt is not at all in control. Every case depressed me.

I once tried to work a harm reduction plans with some, the resistance was amazing, even just waiting and being patient, there was no buy in.

They seem to have the same sort of perceptual distortions as people with depression or anxiety.

 

[JJM 777]

So they are intentionaly making themselves incredibly unatractive to their culture, why are they doing this? What is their motivation to make themselves ugly?

Their motivation is probably the same as why Picasso made so ugly paintings: he somehow imagined them to be beautiful.

Define cureable? Do antipsychotic drugs count? What about anti Depressant drugs?

Some mental conditions are thought to be the result of abnormal activity or passiveness in the glands that produce certain chemicals in the brain. If drugs "cure" the condition, but the condition returns after drugs are withdrawn, then the person is never "cured", but the drugs successfully keep the symptoms under control. Just like a dose of insulin does not "cure" diabetes, but it successfully removes its symptoms for a while, until the next dose will be needed.

BUT read the next quote, and my comment to it:

if your parents verbally abuse you as a child, this will cause you to feel depressed and have low self-esteem - which is to say, you will have less of certain neurotransmitters circulating at any given time. There is no clear distinction between "physical" and "psychiatric" causes.

This is the biggest blind spot of psychiatry: (1) people have financial or social problems => (2) people feel sad, as a perfectly healthy and natural response to the circumstances => (3) people are diagnosed as having a "mental disorder" and given medicine to chemically remove the sadness => return to square one, infinitely.

How do you differentiate between someone who is managing to live a life with a condition like austism do they count as cured? How does that differentiate from anorexics who are managing with their condition?

Let us take dementia as an example, so we have a crystal clear case: you can learn to "somehow live with it", but it does not count as being "cured" and being a healthy person in a medical sense. As long as the condition evidently exists, and special arrangements are necessary to keep it harnessed, it has not been "cured" yet.

Actually there is also a blood test that people take to see if they have schizophrenia.

And there are skeptical psychologists who argue that the thing called "schizophrenia" doesn't even exist really:
http://en.wikipedia.org/wiki/Schizophrenia#Controversies_and_research_directions

 

[paximperium]

This is the biggest blind spot of psychiatry:

What blind spot?

(1) people have financial or social problems => (2) people feel sad, as a perfectly healthy and natural response to the circumstances => [Person copes with it and goes back to his regular life=>Goes back to work] OR Person completely falls apart, ignores family, feels his life is useless, stops sleeping, eating--->(3) people are diagnosed as having a "mental disorder" and given medicine, counseling and occasional Electro Convulsive Therapy to chemically remove the sadness Major Depressive Disorder => return to square one, infinitely==> person can now attempt to deal with his life and his illness with continued medication, familiar support and counseling

Corrected your nonsense for you.

And there are skeptical psychologists who argue that the thing called "schizophrenia" doesn't even exist really:
http://en.wikipedia.org/wiki/Schizophrenia#Controversies_and_research_directions

Yes. I call these scumbag quacks and Psychiatry Deniers.
Edit: Schizophrenia has multiple subtypes and many different underlying causes, many genetic. It is a basket term that identifies a large number of similar presenting psychoses. It is like denying a term like Trauma exist because the gunshot wound has more stigma than a stubbed toe. What nonsense.

 

[Soapy Sam]

There does appear to be a trend to "medicalise" many behaviours which would previously have been seen as simply "odd". I doubt the DSM-5, if it appears on schedule in 2012 will be smaller than the current version. As this is primarily an American publication, but used as a world standard, it can highlight differences in the current medical culture in the US and Eurasia.

I think many people- psychologists, doctors and laymen alike, are unconvinced that some of the conditions described therein actually have organic causes. That doubt may fade as more evidence comes in , or the technology improves, but it's a dynamic process; even among medics, there will be disagreement, at any time, about some conditions.
Among laymen, even more so. Anyone can recognise that a broken arm doesn't work properly. Recognising that broken brains don't work properly can be a lot harder, especially when "working properly" is only recognisable through "incorrect" behaviour, which is culturally defined and varies in time and space.

There is also a concern - valid in my opinion- that the pharmaceutical lobby has a vested interest in the redefinition of "eccentric" behaviour as a "disorder", whereby existing drugs which suppress such behaviour can be prescribed to "treat" it.
The list of persons contributing to the DSM who have (or have at some later time acquired) financial connections to drug companies is longer than makes some interested laymen comfortable.

Plus - let's face it- we all have biases. The shiftless lout down the road who drinks, beats his wife and lives on welfare may be suffering from alcoholism, but it's hard to say how he's functionally different from a drunk. It may be we can cure him, but there exists a possibility that what he actually needs is a boot up the backside.

 

[Nosi]

I am currently in a debate with a friend who is/has suffered from anorexia. She claims it is a disease and I do not on the grounds that it is a conscious action that you have conditioned yourself for. Similar to Alcoholism. I know a lot of experts and psychologists consider it a disease but I don't have a good reason to believe it for a few reasons: its not like testing for cancer or schizophrenia, people say "its a disease" seemingly as an excuse to not own up to their own actions (similar to the way alcoholics and addicts do), the pity factor with which sufferers seem to love, and the fact that you are not born with it or that you are consciously hurting yourself for selfish reasons (again the same way alcoholics, addicts and even cutters do).

I have been told I am very callous on the issue. I admit I do not have much sympathy for anorexics due to the fact that I have dealt with so many people who use the "disease excuse" as a crutch for continuing on with their damaging behavior.

Eating disorders, including Anorexia, are diseases. Their biological tell tale has not been found yet the way cancer's, schizophrenia's, and many other diseases' have been. The tell tale will be found. Their psychological tell tale is sometimes more clear and treated through that path.

At one time, schizophrenia sufferers were told they were simply 'crazy', 'stupid' 'or looking for attention'. Some of the cures have been pretty horrific. Female schizophrenics had their ovaries and wombs chopped out. Schizophrenics have been 'water treated' by repeatedly dunked in bathtubs full of cold water to the point of drowning (which some did). Mental illness was treated in 'hospitals' often referred to as snake pits.

Today, Schizophrenia is usually treated with drugs. Hopefully someday, the medical/psychological profession will find the zig that should go zag and correct it in the eating disorders in that organ between the ears.

 

[Lupie]

Exactly. There are many who are able to be selectively anorexic and even alcoholic but are totally functional and are able to control themselves. I may not condone it but it is not an issue. Damn, my granddad sat around every night and drunk himself to a stupor and then went to work, hung in the weekends and never bothered anyone. When told his liver was starting to go, he stopped.

These are not the ill sick people that I care about and which the OP and sunray breaker seem unable to differentiate from. Many alcoholics can't stop and that is the disorder. That is the problem.

Excellent point. Many years ago, I reached a point in my life where I had been arrested for DUI, had my wife divorce me over my drinking, and I was having major health issues including liver problems. I had every reason in the world to stop drinking, but I couldn't.

In regards to the O.P., from my personal experience, I believe anorexia, like alcoholism, is indeed a disease. However, my belief that alcoholism is a disease in no way meant that I did not assume full responsibility for my actions.

I started drinking knowing full well that others in my family were alchoholics. I knew the risks, I knew of my own pre-dispositions, and chose to drink anyway. I was responsible for the DUI, as well as the divorce and health issues. But, once I was in the nightmare of being addicted to alcohol, my ability to control the drinking was non-existent. I always took full responsibility for my actions, and I knew that I was on a path to self destruction that was of my making, but there came a point where the booze absolutely owned me. I no longer had any choice as to whether I drank or not.

I believe many people with anorexia have the same experience. They start something they know is a risky behavior, they believe they can control it, and before they know it, it takes over their lives. I believe anorexia and alcohol addiction are both diseases, but I also believe that a person can have one of these diseases and at the same time admit that they bear the responsibility for getting themselves into the situation that lead to the disease. It does not have to be exclusively one, or the other.

L