I'm aware my eating disorder is a problem in my life. I'm not paying The New Therapist (TNT) big bucks because my life is fine and dandy and turning out just the way I hoped it would. I'm also aware that things didn't really start to go to pot until the ED kicked in, full-force. This would naturally lead to the logical conclusion that the eating disorder is a problem. And I suppose, when you look at it in more of a vague, almost existential sort of way, I get that the eating disorder is a problem.

But when I have thoughts about restricting, about hiding food, about exercising, about losing weight...I don't see these thoughts as a problem. It's the things that are preventing me from restricting, hiding food, exercising more, and losing weight that are the problem.

My OCD-type thoughts are distressing, and I view them with a mental "Ew, ick, get that out of my head!." The compulsions aren't welcome, but the (temporary) relief they bring from the obsessing is, and so the cycle begins. If you had a magic wand and approached the teen Carrie and asked her if she wanted the OCD stuff gone from her life, she would have said yes, please, take this away from me.

The anorexia is a little different. I do want the eating disorder gone from my life--it's ruined me in every way I can think of--and I'm no longer in denial about the fact that I do have an eating disorder. But when I have ED-related thoughts and urges to engage in behaviors and even (oh lordie...) actually engage in behaviors, I'm not wishing for some sort of magical fairy godmother to make these thoughts and urges go away. Because these thoughts and urges and behavior seem so logical at the time. Feeling like a fat, lazy slug? Duh- exercise more! Feel that you have to eat too much? Slip those eggs into your pocket.

When I was still working full-time in Corporate America last year and in the throes of my exercise addiction, my presence was requested at a lunchtime meeting. This was problematic because I exercised at lunchtime, and if I was at a Big Meeting in front of Important People and theoretically Representing My Agency, I couldn't very well sit there and not eat. I had several days' warning, which gave me plenty of time to stew about appropriate options. As the day grew closer, I debated whether or not I should fake food poisoning to get out of this dumb meeting. Now, even without any eating disorder I wouldn't have wanted to go to this meeting and probably would have come up with half a dozen bizarre excuses not to go that I never would have had any intention of using. My thoughts about the meeting would have been more like "grumblegrumble...stupid lunchtime meeting...grumblegrumble." I wouldn't have contemplated calling in sick to avoid it. But in my mind, the problem wasn't that I was so addicted to exercise that I couldn't contemplate even taking a small break or changing my routine. The problem was (you guessed it) that stupid lunchtime meeting.

In the end, I went to the meeting, divided up my usual lunchtime exercise and tacked it onto the next two days' evening routines.

I'm often unsure about whether I see the ED as sort of a foreign invader or as just a really f*cked up part of my own brain. In a sense, I suppose that's not as relevant as seeing that voice as something I should fight, something I should want out of my life. I struggle every day to see the ED as the problem, and I haven't been able to do it. I suppose this is what the psychologists mean when they define an illness as "egosyntonic." I want it anorexia to disturb me, to fill me with a shuddering dread whenever I think about ever deliberately skipping another meal or tethering myself to a StairMaster. I suppose that's a start, because for so many years, I actively welcomed the anorexia. Even now, though, I find the idea of "having" to eat a meal when I don't want to or not being able to exercise when I want/need to as being the actual problem, not response. I don't know how to get to the point where I actively start fighting the ED off, because when push comes to shove, the thoughts and behaviors don't seem all that problematic.

How did you integrate the idea of "ED as a problem" into your own recovery?

I received a flurry of feedback and comments on my post about Anorexia Mythbusting, and the discussion managed to be passionate and respectful. Which just goes to show that I have the best readers ever. The discussion was fantastic and engaging, and one comment in particular prompted me to do a follow-up post.

Earlier today, Jane (one of the co-chairs of the organization Maudsley Parents) wrote:

I wonder if a lot of the problem here is the word "cause." It seems to me like too simple a construct to be very useful. I find the genetic and neurobiological research on AN very compelling, but I'd be hesitant to say genes or neurobiology cause AN (maybe Radford or others would--I don't know). It seems to me more accurate to say they are responsible for risk. I really think the predisposing/precipitating/perpetuating model makes much more sense than saying, " X causes (or does not cause) AN."

Although I have a special interest in adolescent AN, I agree with Adria and Melissa other eating disorders (as well as disordered eating) merit consideration. Social influence might not be the same across eating disorders.

Humans like to look for "cause," myself included. We want to be able to answer why, to draw conclusions, to figure it out. But as Jane pointed out, the word "cause" as it points to a single factor--be it genetics, models, or mothers--is probably a little over simplistic. The predisposing/precipitating/perpetuating model that Jane mentioned is based on our relatively new understanding of the complex causes of many illnesses.

Take tuberculosis. It was originally thought that you got TB because you came from a bad family or you breathed in bad air. Even after the discovery of the TB bacterium, there was thought to be a simple cause and effect. You breathed in the bacterium, you developed TB. Except it's not that simple. Ninety percent of the people who harbor the TB bacterium in their lungs (after the initial infection, the body walls off the bacteria in the lungs) will never progress to clinical illness or transmit the disease to anyone else. So what's the difference between them and the 10% who do go on to develop clinical disease? Often, TB re-emerges at a point in a person's life when their immune system is weakened, and the bacteria can break free from their "jail" in the lungs. Many things can contribute to a weakened immune system, not the least of which is HIV or other severe infection, but factors also include severe stress and malnutrition. Assuming two people had latent TB infections in their lungs, and one was of a higher socioeconomic class than the other, the person who was wealthier would probably be less likely to develop TB simply because their immune system might have been in better shape. Furthermore, poor people are more likely to live in the types of close quarters that promote TB transmission, and so are probably more likely to inhale the bacterium in the first place.

Does poverty "cause" TB? No. But you can't study TB without realizing the effects of poverty. Just understanding the microbiology isn't enough. It isn't a simple matter of infection causes disease. The infection is a necessary but not sufficient aspect of TB. Vulnerability to TB infection doesn't just start with the infection (or the re-emergence of the infection). It starts with your access to food, with air quality, with a whole host of things that don't have anything to do with the actual bacteria.

It's similar with eating disorders. I would argue that the genetic predisposition is a necessary but not sufficient cause of eating disorders. You don't really see eating disorders in people without the genetic background, but the genetic background alone isn't enough.

So what the heck are these predisposing, precipitating, and perpetuating factors anyway? A good explanation of these factors comes from a continuing education course from the American Dental Hygenists' Association:

[Eating disorders are] considered to be developmental more so than mental. Therefore, predisposing, precipitating, and perpetuating factors are more useful to consider than actual causes.

Factors considered to predispose an individual to anorexia include female gender, family history of eating disorders, perfectionist personality, difficulty communicating negative emotions, difficulty resolving conflict, and low self-esteem. Precipitating factors associated with anorexia focus on developmental changes, such as sexual development and menarche in persons aged 10 to 14 years, which leads to a spurt in weight gain; independence and autonomy struggles in individuals aged 15 to 16 years; and identity conflicts in individuals aged 17 to 18 as they transition from home to college or married life. Perpetuating factors are those that maintain the eating disorder. Examples of these include signs and symptoms of starvation and coping strategies engendered by the eating disorder.

I personally would add illness, efforts towards "healthy eating," dieting, teasing, and other forms of trauma as precipitating factors. But I think this is a good breakdown of what these different factors are and what forms they make take.

A longer explanation (it's slightly dated as it was published in 1988) can be found here: Predisposing, Precipitating, Perpetuating, Professional Help and Prevention for Eating Disorders. This paper also wins the award for today's Best Use of Alliteration.

I promise you that I tried to find other analogies for this, but the best explanation I could think of was a cooking analogy. It's kind of like baking a cake: there are certain basic items that you need to make a cake (flour, sugar, baking soda, etc). You don't typically see anchovies called for in baking. Different cakes have different ingredients (chocolate birthday cake vs. flourless chocolate cake vs. chocolate cheesecake*), and even the same type of cake can have the same ingredients that vary in amounts (more sugar, less leavening). You can add frosting--or not. You can add filling. In the end, though, most cakes have a few staple ingredients that you combine and then bake in the oven. I don't make up a box of Betty Crocker yellow cake mix and expect to pull a Caesar salad out of the oven. It might be over- or under-baked, but it's still cake.

The different ingredients are the predisposing and precipitating factors- not everyone has exactly the same genetic or environmental experiences, but there are often variations on a theme. The "baking" part is where I see the precipitating factors becoming the perpetuating factors. Different ingredients, different baking times, different cakes...but they're still cakes. No one ingredient causes these cakes to spring forth into being (unless you count the baker). Flour doesn't "cause" a cake, nor does sugar, nor does flipping the oven on and popping in a pan.

When trying to figure out what went wrong with a recipe, I often zero in on something. Maybe the oven is on the fritz. Or the baking soda was ancient. Or I was a little short on sugar but hoped for the best. That doesn't mean that that is the only thing wrong with the recipe, just that I focused on one thing. So with eating disorders, focusing on our culture's expectations of beauty as a cause of eating disorders is a little myopic. So is focusing on just genetics and neuroscience.

And a total gold star to whoever made it this far and muddled through my hopeless analogies!

*Yes, I know cheesecake is essentially a custard, but it has "cake" in the name so I'm running with it for the purposes of this analogy.

A number of months back on Twitter, I favorited a humorous tweet that said "I really want to fire the person who writes my internal monologues."

I burst out laughing- I would love to do the same!

Then I started thinking: wait a minute, that person is ME. I write my own internal monologue. Sure, it's influenced by the environment around me--my high school English teacher says "we write what we know." But I get to decide whether I continue my monologue or just hit the delete button.

When I taught a writing class in grad school, I spent one day in the first week talking about a chapter from Anne Lamott's book "Bird by Bird." The chapter I discussed at length? Shitty First Drafts. For someone with extreme perfectionistic tendencies, the idea of letting anything be shitty is anathema. The point of a Shitty First Draft isn't that you let it stay shitty. Writing is valuable in and of itself, but Shitty First Drafts don't pay the bills. No, the point of a first draft is to kind of vomit words onto the page and just start writing. The mess can be cleaned up later.

So what does this tangent on Shitty First Drafts have to do with firing the writer of my internal monologue?

I see the random thoughts that fly through my head every millisecond of every day just like those Shitty First Drafts I told my students to get to know. The thoughts are very real--and so, might I add, are the Shitty First Drafts--but here's the thing: they don't have to be the final draft. I can't delete the thoughts as easily as I can delete the drivel I spent this afternoon spewing forth, but I don't have to let those Shitty First Draft thoughts be the final draft.

I'm the writer. I'm the editor. I can edit those thoughts and decide if I want to keep them or not.

I can't exactly fire the writer of my internal monologue, although writers must be proficient at managing unemployment. And there are days when I would love nothing more than to put my brain out of work for a bit. But my internal monologue writer is also the same girl whose fingers type these blogs out, clackety-clack. This monologue writer is capable of getting paid for her writing by the Washington Post, so clearly she doesn't totally suck.

I doubt I'm ever going to stand in the mirror and look at myself and start crooning love songs into my green eyes. That's not the point of this. I can actually handle the "I SUCK!" shriek-fest melodrama moments to which I am prone. I suck. It's a fact. The end. The thoughts that I find the most frustrating are the constant worries, the doubting, the gnawing fear that I'm not good enough, I'm a fraud, a fake, that I'm never going to make it.

But it's like this afternoon when I was spewing drivel. I stopped writing my Shitty First Draft mid-sentence, and said to myself, "This stream of thought isn't getting me anywhere." Then I just pressed delete and started over.

I have to confess: I have a soft spot in my heart for the Discovery Channel show MythBusters. It's a great show to teach the otherwise uninterested about how to conduct a solid experiment, and there's lots of pyrotechnics--what's not to love? Besides that, the ever-nerdy biologist in me loves to poke holes in commonly held theories and ideas, whether historical, sociological, or scientific.

Which is why I loved this article from (of all places) Discovery News: New TV Show Perpetuates Anorexia Myths. The new TV show, hosted by Jessica Simpson, is called "The Price of Beauty" and will air on VH1. Simpson says this about the show:

“I have always believed that beauty comes from within and confidence will always make a woman beautiful, but I know how much pressure some women put on themselves to look perfect. I am really looking forward to discovering how beauty is perceived in different cultures and participating in some of the crazy things people do to feel beautiful. I know we will all learn a lot on this journey and I am so excited that VH1 is coming along on what I’m sure will be a wild ride.”

Which is all well and good- I have no problem with a show looking at different cultural ideals of beauty, and how it varies from place to place. I think it could be both entertaining and eye-opening.

So what does this have to do with anorexia?

In one of the first episodes, Simpson interviews anorexia sufferer Isabelle Caro, whose appearance in an anti-anorexia billboard caused quite an uproar several years ago. And since Discovery News writer Benjamin Radford did such a good smack-down of the issues, I'll let him speak:

What Isabelle Caro, Jessica Simpson, and the VH1 show don’t realize is that anorexia has little or nothing to do with fashion modeling. Eating disorders such as anorexia nervosa and bulimia are biological diseases, not voluntary behaviors. The idea that a model, photo of a model, or Web site can "encourage" anorexia is not supported by science or research. Images of thin people cannot "encourage" anorexia, any more than photographs of bipolar patients "encourage" bipolar disorder, or photos of diabetics "encourage" diabetes.

Though many people are convinced that anorexia is a threat to most young women because of the media images they see, that’s not what the scientific evidence says. Anorexia is a very rare and complex psychological disorder with many indications of a strong genetic component; as anorexia expert Cynthia Bulik noted in her 2007 study “The Genetics of Anorexia,” published in the Annual Review of Nutrition, “Family studies have consistently demonstrated that anorexia nervosa runs in families.” Most research studies have failed to find a cause-and-effect link between media images of thin people and eating disorders.

...Nearly every woman in America regularly sees thin women in everyday life and the media, yet according to the National Institute of Mental Health, only about one percent of them develop the disease. If there a strong link existed between media exposure and anorexia, we would expect to see an incidence many orders of magnitude higher than is found.

Anorexia is a tragic disease; some young women (and men) do diet to excess and have body image issues. But the scientific research shows that they are the exception, not the rule. The first step in solving a problem is correctly understanding it, and TV shows like “The Price of Beauty” may actually end up doing more harm than good.

Since research suggests that the causes of anorexia have more to do with genetics than thin fashion models, efforts to educate young girls about the artificiality of airbrushed media images won’t do anything to treat or cure anorexia. Girls and young women deserve facts and truth instead of myths and misinformation.

(emphasis mine)

Can I hear a "Hallelujah, amen!"?

If anorexia is seen as a cultural illness by a bunch of diet-crazed beauty freaks, no wonder the allocation for research dollars is minimal, that insurance companies can put up such resistance to covering eating disorder treatment*, that I have been told by so many people to snap out of it and get over it. Yes, I have been exposed to the thin body ideals. Yes, I have probably internalized some of that. No, that has nothing to do with my anorexia.

I wasn't trying to be thin to look like some sort of magazine model; I was terrified of eating and gaining weight. I was aware that anorexia made me look pretty atrocious--I couldn't sense that I had lost weight as my illness progressed, but I could see the gray-yellow skin, the blue nails and lips, the brittle, thinning hair. The culture of thin provides a vocabulary for many sufferers, and it helped me explain to myself and others why I didn't want to eat or tried to avoid eating. I did believe my own bullshit, to some degree. One of the key aspects of anorexia is the inability to understand just how sick you are. So, yeah, telling yourself and your parents and your friends and anyone who cares to listen that your starvation is just an attempt to lose a few pounds and/or just another diet is an easily available defense. It makes sense to you and it helps get those around you to stop breathing down your bony neck.

Anorexia existed before the advent of supermodels, and I have a feeling it will exist after. In the meantime, I'm sending a huge thank you to Benjamin Radford for speaking out on this issue. You can post your own comments at the bottom of the article, so send him some ED Bites lovin'.

*There are other reasons insurance companies can do this, too, not the least of which is the lobbying power fueled by astronomical profits and the fact that it's cheaper to let sufferers die than pay for treatment. But I digress...

It's once again time for your Sunday Smorgasbord! These links are just a sampling of some of the interesting/newsworthy/otherwise mentionable happenings in the field of eating disorders.

Appetite may be partly linked to germs in the gut

Treating daughter's eating disorder must involve entire family

Appetite-focused dialectical behavior therapy for the treatment of binge eating with purging

Eating Disorders: They’re Not Just for Women Anymore (warning: pic could be triggering)

A combination of genetics and optics gives brain scientists an unprecedented ability to dissect the circuits of the mind

Sorority Girls More Likely To Have Bad Body Image

F.D.A. Cracks Down on Nestlé and Others Over Health Claims on Labels

Significant genetic influences on all forms of disordered eating

Elevation of homocysteine levels is only partially reversed after therapy in females with eating disorders

People with EDNOS show just as much functional impairment as those with BN

New Research Roundup On Contributing Factors for Obesity (hint: it's not lack of self-control or willpower)

What nutritionists really eat (@GreyThinking said it best: "If I ate like this RD, my dietitian would tell me it's disordered!")

Can the bacteria in our bodies control our behaviors like a puppetmaster pulls strings on a marionette?

Hour-glass figure activates the neural reward centre of the male brain (not exactly sure what I think of this...)

And last, but certainly not least:

Puddle the turtle has anorexia

Have any ideas for a future smorgasbord? Email them to me: carrie {the little at symbol thingy} edbites {dot} com (sorry for the convoluted email address- I'm trying to cut down on spam...)

I had my third session with The New Therapist (TNT) yesterday, and we discussed some of the chapters that she asked me to read from the book Full Catastrophe Living by Jon Kabat-Zinn.* And one of the segments talked about a woman, Mary, who felt like this huge truck was always on her heels. When asked what the truck represented, she responded that it was her impulses and cravings, her thoughts and feelings. In other words, that truck was her mind.

Substitute "obsessions and anxieties" for "impulses and cravings," and you pretty much describe me. I have this mental feeling of something always being on my heels, that I'm being chased or followed (not literally, of course). I always feel like I have to keep pushing my brain to stay one step ahead, to anticipate what might go wrong or what might happen next. It's that perpetual stream of "what if" questions that always seem to plague me. It's the fact that my brain never seems to shut off--it's always whizzing away with some thought or idea or worry. These leave me feeling mentally exhausted and frustrated because that truck--my thoughts--were always pushing me and following me.

So I expanded with TNT on this metaphor. I think my exercise habits were part of a way to try and "outrun" this truck. If my normal everyday life was the equivalent of "walking," and it left this truck always on my heels, then maybe if I walked a little faster, the truck would leave me alone. Or I could at least get a bit of peace and quiet. And to some extent, it worked. Part of the purpose of exercise was to exhaust me to the point where I was too tired to worry- or at least too tired to care. The "truck" was off my heels for at least a little bit.

Except the truck always came back, and I started adding more exercise so I could try and find more peace of mind. And yeah- we all know where that brilliant idea led.

Now I'm back to living life with this truck dogging every step I take, every thought I have. Part of what TNT explained is that one of my tasks in recovery is to accept and make peace with the truck. To stop being so intimidated and frightened of it. The goal is less to make the truck go away, or try to convince myself it's not there--no amount of therapy is going to make me into a not-anxious person. The idea is to make the truck less distressing and annoying, to stop fighting the fact that it's following me. To make the truck into more of a butterfly or at least more like my shadow. It's there. I know it's there. I notice it, but it doesn't bother me. That's the difference.

What's your truck? How have you learned to live with it?

*She describes her approach as CBT seasoned with mindfulness techniques. Works for me.

Yesterday, I finished reading a book called "Weekends at Bellevue" by Julie Holland, which chronicles nine years in the live of a psychiatric ER doctor in New York City. It was a tremendously absorbing read, and it gave me a lot of insight into what might be going on in the minds of the people who have treated me in crisis and tried to talk me down from the rafters, as I insisted that the Saltines and cranberry juice would make me fat and that I really didn't need sleep/food/water.

But it was a passage on the last two pages of the text that really struck me:

There is a diaphanous membrane between sane and insane. It is the flimsiest of barriers, and because any one of us can break through at any given time, it scares all of us. We all lie somewhere on the spectrum, and our position can shift gradually or suddenly. There is no predicting which of us will be afflicted with dementia or schizophrenia, who will become incapacitated with depression or panic attacks, or become suicidal, manic, or addicted. None of these states of mind are uncommon, and all of us have friends and family who are suffering with some degree of psychiatric illness. Many of us should be grateful for our relative mental health.

The reality is this: All of us, to some degree, are mentally ill. We get paranoid, anxious, depressed, and insomniac. We alternate between delusions of grandeur and crippling self-doubt, we suffer from paralyzing fears and embarrassing neuroses. We all have compulsions to do things we know we shouldn't, and there are millions of us with addictions, whether to gambling, drinking, dieting, or playing Second Life. Every one of us has psychiatric symptoms, many of them serious enough to warrant attention, even if they are not incapacitating. But few of us are willing to let on that we are suffering. This secrecy and shame compounds our avoidance of those who have been officially diagnosed as mentally ill...

We avoid dealing with psychiatric patients because we hate to see things in others that we don't want to see in ourselves: weakness, need, despair, aggression. Our experiences with the psychiatrically ill often fill us with dread; they confront us with our own terror or reaching a catastrophically altered state from which there is no return. We should be compassionate to those who stumble out of our lockstep. Yet in our culture, the mentally ill are demonized and shunned. They are ostracized and marginalized as a by-product of our primal fear of going crazy ourselves. It is the nightmare of our own "shadow self," as Jung called it, that allows us to treat others so harshly.

In attending many presentations and talks about eating disorders, one of the more fascinating topics I've heard mentioned was interoceptive awareness. Interoceptive awareness (IA), as a research article on the subject succinctly put it in the title, is "the sense of the physiological condition of the body." What this means is that when you sense things like "pain, temperature, itch, sensual touch, muscular and visceral sensations, vasomotor activity, hunger, thirst, and 'air hunger,'" you are using IA. The input is internal, unlike other senses that are more external. Visual input comes from outside your body; a sense of exhaustion is more internal. Furthermore, an ability to recognize your emotions is also considered part of IA, and all of these IA tasks occur in an area of the brain known as the insula. Wikipedia tells us that the functions of the insula "include perception, motor control, self-awareness, cognitive functioning, and interpersonal experience."

Scientists have long speculated that people with eating disorders have impaired IA. A recent research review article by Walter Kaye examines the evidence of dysfunction in both the insula and in IA as one of the drivers of ED behaviors (Kaye, Fudge, and Paulus, 2009). Research on the relationship between EDs and IA dates back to this paper from 1978 by Garfinkel et al. Impaired IA would help explain how a person with AN might be able to continue to starve themselves--their hunger cues might be impaired. Or how someone with BN might be able to continue to binge--their satiety cues might be impaired. Furthermore, people with eating disorders often struggle with identifying emotions, body size and shape, and fulfilling other biological needs (such as sleep). Poorer IA is also associated with poorer ED outcome (Lilienfeld et al, 2006). I've blogged on my own (mis)adventures with IA here.

I'm still not very talented at figuring out whether I'm hungry or full, whether I'm tired and need a nap or just need to stretch my legs. Some of the hunger/satiety issues were probably thrown off by the eating disorder, but some of it may just be the way I'm wired. I've been in the midst of several full-blown hypoglycemic episodes (feeling faint, shaking, sweating, vomiting) and thinking "How could that be? I don't feel hungry." Obviously. I wasn't trying to delude myself- I've had ED-induced hypoglycemic episodes where I knew damn well it was because I hadn't eaten and I played the green-eyed ingenue. But there were plenty of times where I delayed a meal because I didn't feel hungry and then WHAM! Which is a great example of impaired IA, if nothing else.

A new study published this week found that levels of Brain Derived Neurotropic Factor (BDNF; which encourages the growth of new neurons and helps existing ones thrive) were correlated with interoceptive awareness and maturity fears in people with anorexia and/or bulimia (Mercader et al, 2010). Specifically, the researchers found that higher levels of BDNF were correlated with lower interoceptive awareness and higher maturity fears. The authors suggest that BDNF levels may play a role in regulating ED psychopathology via impaired IA.

Previous research has explored a link between BDNF and both anorexia nervosa and bulimia nervosa.

I'm not thinking that testing BDNF levels are going to become standard of care anytime soon--BDNF is associated with impaired IA but that doesn't tell us much. Does BDNF have an affect on IA or is it just a bystander? How might BDNF affect IA? Does decreasing BDNF levels increase IA?

Like so much research, this paper raises more questions than it really answers. Still, I find it all very interesting.

Our data suggest that BDNF levels may influence the severity of the ED by modulating the associated psychopathology, in particular through the impairment of interoceptive awareness.

As I mentioned a few weeks ago, I decided to update the blog format for any number of reasons, not the least of which were:

make the information more accessible (there's a LOT of it!)
make the website look prettier (sigh...vanity)
make ED Bites easier to navigate

I realize that the sidebar stuff is rather messed up as yet, and it will probably take me a day or two to reorganize everything.

I also intend to group my posts in several different "categories." The most obvious to me are an "About Me" section (which is where I'll post the wordle for all eternity, so you can light candles, etc, and tell it how much you loved it), a "Personal" section, a "Research/Nerd" section, and a "News/Smorgasbord" section.

I realize that asking you for any other suggestions you might have may be a little premature since the links on the side are still so wonky, but if you do have any thoughts or suggestions, please do share them!

This recent study, titled "Psychopathology in underweight and weight-recovered females with anorexia nervosa," beautifully articulates something that I've struggled to put into words. The study found that weight recovery in people with AN dramatically decreased psychopathology.

No, no--it's not that weight restoration cures everything! Because my life right now is an obvious example that this isn't exactly true. I would never say that weight gain isn't necessary, just that it's the necessary first step towards a meaningful recovery. If weight gain "cured" anorexia, then there wouldn't be the tremendously high rates of relapse that we see. The difficulty with weight gain is consequently keeping the weight on for long enough to get physically used to your new body and to begin the mental healing process.

But I digress.

The reason I find this article so incredibly interesting is how it managed to examine the relationship between somatic factors (ie, weight) and psychological factors (ie, ED psychopathology). Usually, the mind/body connection is seen as something very heebie-jeebie and New Age-ish, an idea sprung from the mind of a few pot-smoking hippies reeking of patchouli. But the brain was connected to the rest of the body- at least the last time I checked. The brain is an organ, just like your heart or your liver.

The mind/body separation in Western culture has been around for hundreds of years and has resulted in some rather interesting separations in medicine. The need for mental health parity is one of them, although that could also be interpreted the machinations of a bunch of cheap-ass insurance companies. With eating disorders, the assumption was that the ED thinking caused the behaviors that caused malnutrition and weight loss. It was a one way street. Although this is somewhat true (most people with AN don't start out malnourished no matter how catastrophically they end up that way), the opposite is also true. Low weight can cause ED thinking, which causes ED behaviors and a further increase in malnutrition, and I think that's what they call The Perfect Storm.

The body and mind aren't separate. Your brain uses approximately one quarter of the calories you eat (500/day) and is essentially a glucose hog. If you starve your body, you starve your brain. I managed to shrug many of the physical effects of anorexia off, but the cognitive effects really got to me. The knowledge that I can't preferentially shunt calories to my brain has helped me resist urges to restrict. I know I'm not the next Einstein, but my job requires a lot of intense, deep thinking, and anorexia would grind that to a halt. I don't miss being caught in the circular ED thinking, worry about what I ate, what I will eat, what I might eat, and exercise and fat grams and everything. If I delay my meals or snacks for any length of time, I notice a return of the anxiety and ED thinking, even if I don't notice a difference in my hunger levels.

It seems odd to think that something as simple (though fraught with challenges for those of us with ED) as eating could improve state of mind. It's not a cure, but it should stop being so surprising to so many people.

(An interesting note: the one area of psychopathology that didn't improve with weight gain was perfectionism, which emphasizes how this is a long-standing personality feature of many with EDs rather than limited to the time when one is acutely ill with ED.)

Today's New York Times had an eye-opening article on small changes in diet and exercise and obesity. The hallmark of some of the most recent anti-obesity initiatives seem to be small changes. How many times have you heard that if you cut just 100 calories a day, you can lose 10 pounds in one year? I don't have enough fingers and toes to count how many times--and perhaps even more annoyingly, it's flat-out wrong.

The secret to weight loss, we are told, is that you have to burn more calories than you consume. Which is technically true, it's just that the body's metabolism doesn't use the kind of straightforward arithmetic that we learned in elementary school and that you'll find in calorie counters and on pedometers everywhere. It's more like ultra-advanced calculus, where there are numerous factors that go into how many calories we consume and how many we use.

From today's article by Tara Parker-Pope:

A person’s weight remains stable as long as the number of calories consumed doesn’t exceed the amount of calories the body spends, both on exercise and to maintain basic body functions. As the balance between calories going in and calories going out changes, we gain or lose weight.

But bodies don’t gain or lose weight indefinitely. Eventually, a cascade of biological changes kicks in to help the body maintain a new weight. As the JAMA article explains, a person who eats an extra cookie a day will gain some weight, but over time, an increasing proportion of the cookie’s calories also goes to taking care of the extra body weight. Eventually, the body adjusts and stops gaining weight, even if the person continues to eat the cookie.

Similar factors come into play when we skip the extra cookie. We may lose a little weight at first, but soon the body adjusts to the new weight and requires fewer calories.

That's not to say that doing small things is useless--they can have profound impacts on our health even if our weight doesn't budge one bit.

Writes Parker-Pope:

“There is a much bigger picture than parsing out the cookie a day or the Coke a day,” said Dr. Jeffrey M. Friedman, head of Rockefeller University’s molecular genetics lab, which first identified leptin, a hormonal signal made by the body’s fat cells that regulates food intake and energy expenditure...“I’m not saying throw up your hands and forget about it,” Dr. Friedman said. “Instead of focusing on weight or appearance, focus on people’s health. There are things people can do to improve their health significantly that don’t require normalizing your weight.”

Which pretty much hits the nail on the head. Weight is not a behavior we can change at will. I'm all for kids playing outside more and watching TV less, for them to eat wholesome foods and a variety of treats and sweets. Maybe no one's weight will change as a result of this, and that's just fine.

I've found small changes to be some of the hardest--and therefore most worthwhile--changes I've made in my recovery. Small things, such as getting rid of "low-fat" foods and working to get to bed at a reasonable hour, haven't budged my weight but have had a noticeable impact on my recovery.

What small change have you made that's helped (or hindered) your recovery?

It's that time of the week again- the Sunday Smorgasbord! I'm going to try the smorgasbord like I did last week, with more links and less in-depth coverage. Please be sure to let me know what you think of the different format in the comments setting. Thanks!

Fruit fly tongues and feeding behaviors

In class, in treatment: Treating EDs in college

Gene variations in endurance athletes

Emily Program SpeakUP Web Rally on ED Insurance Coverage

Why the body isn't thirsty at night

Bulimia patients show altered body schema and self-representations

Chronological sequences of specific eating and anxiety disorders

Patterns and prevalence of disordered eating and weight control behaviors in women ages 25-45
Caffeine consumption among eating disorder patients: Epidemiology, motivations, and potential of abuse

BBC Breakfast speaks with 12-year-old recovering from anorexia

ED patients show signs of humanity as they have improved self-esteem when treated kindly

Melissa (of the blog Finding Melissa) presents with Prof Janet Treasure in London- click here to download audio and video versions of the talk.

The upside of depression

How the addition of BED may affect employers and insurers

So it's the last day of National Eating Disorders Awareness Week. I'm guessing most of my blog readers are aware of this, and I think improving awareness of eating disorders is a Very Good Thing. There is still so much misunderstanding about eating disorders, and it kind of irritates me. Some things about NEDAW irritate me, too. For starters are the atrocious headlines in ED stories, such as "Anorexia: Starved for Love." Yes, people with anorexia are starved, but they're primarily starved of food. That can cause sufferers to starve themselves of other things besides food, true, and love can go a long way in recovery, but lack of love isn't an eating disorder.

And I'm left with very mixed feelings about the ways in which we try to prevent eating disorders. Much of the information out there is about loving your body and improving self-esteem and why you shouldn't diet--all of which is good information, but I'm not so sure how it prevents EDs (excepting the last bit). The irony is that explaining what EDs are and what the symptoms are and how to help a friend can trigger ED behaviors. Yes, dear, starving yourself and puking are very bad and you shouldn't do them.

No kidding.

I had a friend with anorexia, and I remember distinctly thinking when I first started on my new healthier eating/exercise program that I didn't want to become anorexic. I knew what anorexia was and I knew it was a bad thing. I was aware of eating disorders. Not like I am now, but I knew that looking at fashion magazines was considered Bad for Women and that if I let my (hypothetical) children emote freely and didn't let them have Barbie dolls, then they probably wouldn't get anorexia. Right?

I was--okay, I still am--a bit of a do-it-yourself-er feminist. Raised in a rather conservative family, I stumbled across feminism through surreptitious reading in my American history class in high school and learned, quite possibly for the first time, that feminism meant more than bra burning. I was still in this phase when I had my first initial crash course on eating disorders by way of my best friend in college. I didn't do a whole lot of researching, as this friend was in recovery and not in need of huge amounts of eating support, because I'd Heard The Message. I figured that if I could help my friend get over the evils of wanting to look pretty and have the thin, "perfect" body that was required of her by OMG TEH MENZ!!!!1!, then she would finally overcome the last bit of her eating disorder.

I was so naive.

I knew nothing of biology, nothing of the links to anxiety disorders, nothing of any of this. I had heard the message of NEDAW, essentially, because I thought if I would help people love their bodies then there would be no eating disorders.

Yes, in recent years NEDAW has begun to integrate some science, but in many areas, NEDAW is also called "Love Your Body Week." I'm not against having a "Love Your Body Week" but I'm not sure how it will prevent eating disorders. It's like having the theme of the Depression Awareness Week be "Don't Worry, Be Happy." Rastafarians and reggae music is nice, and it might lift your spirits, but its relationship to depression is unclear.

Yes, many people with eating disorders struggle with body dysmorphia, and learning to accept and live in your own personal body is a major task for people in recovery. I'll admit it's one of mine, learning to move through the world in a body that is chubby round jiggly chunky lumpy not emaciated. It's a major problem for people with eating disorders, and it's not entirely illogical to think that if we can prevent people from hating their bodies, we can prevent eating disorders. Except that extreme body hatred is often the result of an eating disorder (or at least greatly inflated by it), not an actual cause of an ED.

I'm not anti-NEDAW. I'm not anti-Love Your Body messages. If there was a little less overlap between the two topics, I probably wouldn't be quite so bothered.

What NEDAW message do you want people to hear?

I was in the middle of writing another post when I got the ever-appreciated ding that a friend had sent me a message via Facebook chat. I met this friend (let's call her N. to keep her anonymous) in the writing program I was in. We shared a room at a conference and generally got along splendidly because of some similarities in our pasts. Both of us had our share of mental health issues and had spent time in psychiatric units. We discussed our various medications with no small amount of glee. And we both found ourselves struggling after graduation, both of us having difficulty finding our way in the world. We kept in vague touch, although neither knew the full story of what happened with the other person.

So N. asked how I was doing, and I decided to come clean with the story of my relapse and what I was up to now, and I was relieved to hear what kind of support I got. It was so nice to just share what had been going through my mind, and how I felt like our program screw up because of all my issues. And N. said, basically, no, I couldn't be the program screw up because that job was hers. I was just about to assure her that this was one job she was safe resigning from when I had to laugh. It was like those interminable conversations with other people at treatment, as to who was the fattest. And everyone always insisted it was them no matter how often the other girls said that no, they were the fattest ones there. It was a losing argument, and no one ever had an accurate idea of their true shape and size and the end of the discussion, but we always persisted on having them anyways.

Still, it was reassuring to know that someone else was floundering in life and thinking they were a failure and wondering how they were going to be a successful writer when all they could see was this big black wall of FAILURE sitting in front of them.

As I was chatting with N., I was reminded of a visit our program got by someone who had graduated several years previously. She told us of how much of her early career could be described in one word: flailing. All of us in the program laughed nervously, knowing that this experience was waiting for us, too.

And it was. It really, really was.

So I reminded N. about this quote, and I told her: Maybe we're not failing. Maybe we're just flailing.

She agreed and the conversation drifted, as conversations tend to do. We eventually started talking about our current writing projects, me with my freelance projects and her with her novel. Then N. said something rather profound:

Just sitting down to write every day is an act of amazing courage on my part.

I had to agree.

It's hard for me to express to other people just how much courage I have to muster up to get through the day, how much energy it takes to look "normal" sometimes. Sometimes getting out of bed is an amazing act of courage. Eating sure is.

We all have things--courageous things--that we do every single day. Just because they're ordinary doesn't make them any less courageous.

What's your "amazing act of courage"?

So I had planned to do part two of the DSM-V eating disorders series, but that got sidelined by a massive bout of anxiety. I can't think straight. I can hardly sit still. I have chewed my nails into nubbins (not that there was a lot for me to chew, but somehow I managed).

I have a lot of uncertainties in my life: if I'm going to be able to make a go at being a writer, if financially everything will work out, if I'm ever going to be free of this ED, if if if if if.

I hate "if". Tell me "when." Now would be nice.

I spent much of the evening working on my writing projects and getting nothing accomplished because my brain kept zooming from one worry to the next. I eventually gave up and flipped through my newest National Geographic.

In some sense, I'm tolerating the anxiety because I haven't completely imploded. In another sense, I want to just crawl out of my own skin. My mom asked if there was anything she could do to help with the anxiety. I looked at her and said: "Could you get me a treadmill?" It's not even the burning calories part that's attractive--that frenetic movement seemed to exhaust my brain so that it was almost impossible to worry so much. And during exercise, my brain shut off completely.

So I'm going to go try and get some sleep and hope that everything works out.