...like a little baby goat!

Yep, you guessed it: it's your weekly reminder to go out and vote for ED Bites for the HealthBlogger 2009 Awards.

I've gotten more votes than I ever expected, and I thank you all from the bottom of my heart. However, if you haven't yet voted, do your civic duty and GO VOTE! If you're not a Wellsphere member already, you'll have to register, but it's super-easy. All you need is a valid email address, and they never spam.

Click on the "vote now" in the link below or on the same widget on the top right-hand side of my blog.

Carrie A. http://www.wellsphere.com/linkOut.s?link=http%3a%2f%2fwww.edbites.com

Also, if someone can come up with something cute that rhymes with "vote," I'd greatly appreciate it. I've used "goat" and "stoat" and unless you want to vote like a little baby oat next week, I'd love some suggestions.

I was listening to the radio in the car today, something I usually don't do. For one, I haven't yet found a station that plays the songs I like (seeing as it would have a listenership of, like, me, I'm not exactly surprised), and two, I hate the ads. I have developed quite a music collection over the years and spent hours downloading my CDs to my iPod. Today, however, I was in my mom's car and lacked the high-tech paraphernalia I usually use. So radio it was.

This experience- about 30 minutes of radio in total- just confirmed my distaste for radio in general and ads in particular. Not just any ads, you see, but food ads. Specifically ads for foods that are considered the stereotypical female diet foods. Foods like yogurt.

This particular ad was for Kroger's lowfat yogurt, yogurt that was not just advertised as "lowfat." No, this yogurt was called "Kroger's Guilt No! Delicious Yes! Lowfat Yogurt." Which would have been bad enough, but, of course, it wasn't. I didn't get to write down the entire copy, but I did scribble down the line that absolutely had my jaw on the floor:

If you don't know that delicious comes with a serving of guilt, you're not a woman with a waistline!

Holy leaping stereotypes, Batman! I tried to analyze how many stereotypes were in that one little tag line, but I lost count. Just totally lost count.

I didn't know that one little ad--one thirty second slot of time--could so smashingly capture everything that is wrong with how food is advertised and conceived of in this country. Clearly, I was wrong.

Instead, I will leave you with my absolute favorite video segment on women and yogurt by Sarah Haskins. You will never (and I do mean never) think of yogurt the same way again.

"Coping skills" is a term that I hear a lot in therapy. It's also a term that totally flummoxed me. I'm having anxiety so bad that I want to literally claw my way out of my skin and you tell me to do a crossword? Thanks, but I think I'll use that pencil to gouge out my own eyeballs.

Of course crossword puzzles don't help panic attacks when you're in the moment. But the idea is to start using your coping skills before you get to the I-wanna-be-like-Oedipus-and-blind-myself-with-a-stick stage. I just needed help figuring out what the hell a coping skill was, anyway. I had several that reliably decreased anxiety and improved my mood, but they were pretty self-destructive. I got worksheets with ideas, some of which were useful and others of which didn't jive with me at all. Paint my nails? I don't know that I own nail polish!

However, the lovely Grey Thinking has come to our rescue with a series of posts on underrated coping skills that are, in my mind, spot on and really fantastic.

Underrated Coping Skill 1: Card Stores
Underrated Coping Skill 2: Bulletin Boards
Underrated Coping Skill 3: Kudos Charts
Underrated Coping Skill 4: Crafting
Underrated Coping Skill 5: DVDs

As well, Dr. Joy Jacobs recently posted a list of Priceless Stress Relief Tips compiled by a patient of hers to help her cope with the recovery process.

So what's your favorite (positive!) coping skill? Why does it help you?

Most humans like a sense of control in their world. Some of us (like me) like a sense of control more than others. And need for control stems from an inability tolerate uncertainty. I don't like surprises--not even in the form of presents. I don't like suspenseful movies. I don't like decisions hanging over my head. I like things to be clear and predictable.

I stumbled across a study that was published last year in the research journal Science titled "Lacking Control Increases Illusory Pattern Perception" by Jennifer Whitson and Adam Galinsky that addresses some of my favorite nouns bandied about in the eating disorder world: control. fear. superstition. rituals. A press release said that

[The researchers] showed that individuals who lacked control were more likely to see images that did not exist, perceive conspiracies, and develop superstitions.

"The less control people have over their lives, the more likely they are to try and regain control through mental gymnastics," said Galinsky. "Feelings of control are so important to people that a lack of control is inherently threatening. While some misperceptions can be bad or lead one astray, they're extremely common and most likely satisfy a deep and enduring psychological need."

According to Whitson, that psychological need is for control, and the ability to minimize uncertainty and predict beneficial courses of action. In situations where one has little control, the researchers proposed that an individual may believe that mysterious, unseen mechanisms are secretly at work. To test their theory, the researchers created a number of situations characterized by lack of control and then measured whether people saw a variety of illusory patterns.

"...People see false patterns in all types of data, imagining trends in stock markets, seeing faces in static, and detecting conspiracies between acquaintances. This suggests that lacking control leads to a visceral need for order – even imaginary order," said Whitson.

This reminds me a lot of how the need for control is discussed in ED treatment. Even though an eating disorder isn't about control, the need for control is the underlying theme of many eating disorder behaviors, whether it is controlling what is consumed, purged, exercised, or what have you. In so many personal accounts of eating disorders, I have heard statements saying something along the lines of "when everything else felt out of control, at least I could control my food."

But this research has made me look closer and think harder about what is actually going on. Stress is a frequent trigger of eating disorder onset and relapse, and one of the most stressful things is feeling like you have no control over your life. I've been there. It sucks. So maybe if the eating disorder wasn't "about" trying to control every aspect of my food intake, maybe this lack of control contributed to why I fell for the ED delusions hook, line, and sinker.

If I was like the people in Whitson's and Galinsky's study, then the times I was under stress, I would have been much more likely to assume that my decrease in food and increase in exercise helped make the situation resolve. It helped cement the superstitious beliefs that if I eat more than X calories or exercise less than Y hours or don't take at least Z laxatives, then all hell would break loose. Of course, nothing makes you feel more out of control than an eating disorder, so the beliefs and the need for pseudo-psychological order only increases. The "unseen mechanisms" proposed by the researchers was, in my case, the eating disorder. It simultaneously made the world go 'round, and also made my life cohere into a series of actions that I could understand and manage.

On the flipside, this research suggests that helping people gain control over their lives (which, in the case of EDs, would start with stopping symptoms) would decrease their endless mental gymnastics in trying to find a safe food, or a safe place to purge.

This has really made me re-think the role of control in eating disorders.

Last week, a fantastic special on mental illness aired on PBS called Minds on the Edge that addresses many of the legal and ethical issues that people with mental illness (and their loved ones!) will face.

Although the whole show was fantastic (and is worth watching), it was the hypothetical story of "Olivia" that really caught my attention. While a college student, Olivia begins developing symptoms of mania, causing her friends and professors to worry. Olivia, however, thinks she is just fine, dammit, and wonders what the fuss is about. Her parents come for a visit and find her mental and physical state so disturbing that they bring her to the emergency room.

Except that's not the end of the tragedy, as it might be with a broken leg; it's just the beginning.

I couldn't embed the videos on the "Olivia" segment, but you can watch it yourself here:

Part One
Part Two
Part Three

Although this segment doesn't really mention eating disorders, I think it raises many of the issues that our medical and legal system fail to address in illnesses that are anosognostic. We are very used to assuming that people are aware and conscious of their own choices--and most of the time, we're right. But when we frame life-threatening brain diseases as just a series of tragic but stupid decisions, we're ruining lives.

There is no easy fix--one of the panel participants in this program called the mental health system the definition of insanity (though no doubt insurance companies would consider this a pre-existing condition). But we can't start with the fix until we start reframing how we think about all mental illness, eating disorders included. These illnesses aren't about unresolved conflicts or boundary violations, and although the behaviors frequently make sense to the sufferer and do have an adaptive function, they're not just a poor coping mechanism.

Be sure to explore the rest of the Minds on the Edge website and share your thoughts in the comments. There are also audio and transcripts available if you want to listen on your iPod or if you'd rather read it.

The pressure to be thin is usually considered a fairly 'modern' phenomenon, but an interesting 2000 letter to the Journal of the American Academy of Child and Adolescent Psychiatry demonstrates that even women in ancient Rome felt the pressure to diet and lose weight.

The pressure to be thin on adolescent girls in ancient Rome is a relatively short letter, and I've copied the text here:

Garner et al. (1985) wrote about the present “unprecedented emphasis on thinness and dieting” which is one factor responsible for the increase in anorexic and bulimic disorders. It is generally believed that dieting in pursuit of a thinner shape and slimness as a standard for feminine beauty are modern attitudes. However, a clear account can be found in the ancient comedy Terence’s Eunuchus.

Terence (Publius Terentius Afer) (c. 190–159 BC) was a Roman comic poet. His 6 surviving comedies are Greek in origin but describe the contemporary Roman society. Eunuchus was probably presented in 161 BC. In this comedy, a young man named Chaerea declares his love for a 16-year-old girl whom he depicts as looking different from other girls and he protests against the contemporary emphasis on thinness: “haud similis uirgost uirginum nostrarum quas matres student demissis umeris esse, uincto pectore, ut gracilae sient. si quaest habitior paullo, pugilem esse aiunt, deducunt cibum; tam etsi bonast natura, reddunt curatura iunceam. itaque ergo amantur.” (She is a girl who doesn’t look like the girls of our day whose mothers strive to make them have sloping shoulders, a squeezed chest so that they look slim. If one is a little plumper, they say she is a boxer and they reduce her diet. Though she is well endowed by nature, this treatment makes her as thin as a bulrush. And men love them for that!) Then he describes the girl he loves: “noua figura oris . . . color uerus, corpus solidum et suci plenum” (unusual looks . . . a natural complexion, a plump and firm body, full of vitality). So he opposes vividly the typical thinness of the girls of these times to the blossomed body of the girl he loves.

This Roman pressure on girls to diet to meet the social expectations for thinness represents a clear precedent for the current emphasis on thinness. It is clear that in Ancient Rome, as in today’s society, there were multiple factors related to the development of body image concerns which today are often a precursor to eating disorders. These include cultural pressures to strive to develop and maintain a particular body shape in order to be considered attractive and then valued as a woman. Here, Terence mentions Chaerea’s preference for a plumper girl, while mothers usually wished their daughters to be thinner. Although the media influences that today are critical in influencing images of a perfect body were not present in Ancient Rome, it is clear from this part of the text that pressures concerning appearance existed long before the 20th century.

Of course, this little tidbit is making my epidemiologist's mind whirr. Was Terence's assessment of the thin-is-in culture in ancient Rome a universal female thing, or was it restricted to those in the upper classes, or those in urban areas? What were the rates of eating disorders during that time? What, if anything, is the relation between the pressure to be thin and the rate of eating disorders? Did those who developed an eating disorder have the same kind of personality traits that researchers so often find in today's sufferers? What does this say about how cultures in different times and places view women and women's bodies?

What a fascinating little tidbit!

via Mind Hacks

...like a little baby stoat!



Thanks to all of you wonderful readers out there, I am currently #7 in the People's HealthBlogger Award 2009. This is just a little reminder to keep those votes coming! Every last one is appreciated. Click on the "vote now" link below to work your magic. You do have to join Wellsphere, but they don't spam and it's super-easy.

Carrie A. http://www.wellsphere.com/linkOut.s?link=http%3a%2f%2fwww.edbites.com

Regardless of the outcome, I would totally vote for you all in the Best Readers contest. You rock!

No, I'm not talking about bowel function for once...

Instead, I'm reading a book titled "The Geography of Bliss" by Eric Weiner that is simultaneously amusing and fascinating. The basic premise of the book is that author travels around the world to see how different countries find happiness. On his visit to Iceland, Weiner gets talking about how unhappy experiences are relevant to happy ones, especially in terms of art/writing/etc.

Crap plays an important role in the art world. In fact, it plays exactly the same role as it does in the farming world. It's fertilizer. The crap allows the good stuff to grow. You can't have one without the other. Now, to be sure, you don't want to see crap framed at an art gallery, any more than you want to see a pound of fertilizer sitting in the produce section of your local grocery store. But still, crap is important.

Crap, really, is important to life. I didn't start to deal with my anxiety and food and depression issues until they turned from a slightly sour bottle of milk that you could push to the back of the fridge and ignore to a grand, stinking compost heap. We all have these compost heaps in our lives. It's a matter of deciding whether you're going to let them sit there and attract rats, or use them to fertilize your life.

It's not about making the crap "worth it," because, hey, it's crap. It's about taking something that would otherwise go to waste (ie, the really bad times) and using it to help grow the good.

I always thought fun was an over-rated concept. It was doing the best that mattered. It was succeeding that mattered. I was never against fun, but I was always afraid that really enjoying what I was doing would somehow detract from the achievement. That is, the fact that I was miserable while attaining all A's in high school and college, made those grades even more impressive than if I had enjoyed myself.

Yeah, I know: it doesn't make much sense.

Fun was a privilege. I would only allow myself to relax if I had completed all of my tasks for the day. The irony is, of course, that I was a tremendous overachiever and always had far more to do on my list than could ever be done by a normal human during a 24-hour period. So fun was pretty much non-existent. The ultimate irony is that I probably would have been a lot more productive if I had done something fun and given my poor little flambeed brain a break.

Fun is also something I struggle with in all things related to eating and exercise. I mean, I loved my endorphin highs from starvation and exercise, but that's quite different from "fun." I can enjoy cooking, but I have a problem with enjoying eating. And I have equated exercise with (essentially) torture, so sometimes I feel like a lazy git even though I'm riding my bike regularly. Why? My bike is fun, ergo, it can't be exercise.

I've realized lately just how much company I have in this category. I understand that others with eating disorders would be keeping me company, but so many people I know have issues with enjoying food and exercise/movement/etc. It's the motto of "No pain, no gain." Shouldn't it be "No pain, no Ben Gay, ibuprofen, or a vodka chaser"?

I saw this video on Facebook and, to me, it just epitomizes how fun should be a part of our lives. The video was made as part of an initiative by Volkswagon called The Fun Theory, which looked to see how something as simple as fun would change people's behaviors. In this case, the people changed a stairway in Sweden to a big piano keyboard to encourage people to take the stairs.



Taking the stairs, is/was an ED thing with me- it was a rule, a must do. Seeing this video, I just want to run up the stairs and play and be goofy. One similar outcome, two very different motivations.

Anyone want to do a Chopsticks duet with me?

(As a fun but random side note, I've played the piano piece that was the background music at the end of the video.)

Samantha Henig, an editor at Slate's Double X, sent me the link to her latest video about her experience on the Master Cleanse. After a massive misunderstanding on my part (I thought she was trying to sell me something, and though I apologized on Twitter, I am doing it again here: So sorry, Samantha! My fingers got trigger happy and I jumped the gun!), I finally watched the video and had to share it here:



To me, Henig absolutely hit the nail on the head when she talked about how the Master Cleanse was really just a socially acceptible way to lose a lot of weight very quickly, and that it was the mental effects of the cleanse that were far more dangerous than any physical risks.

What did you think?

Previous "In the Name of Health" blog series:
Part One
Part Two
Part Three

Funny and informative. Due yourself (and your mind!) a favor and watch this.

The Colbert Report	Mon - Thurs 11:30pm / 10:30c
The Obesity Epidemic - Amy Farrell
http://www.colbertnation.com/
Colbert Report Full Episodes Political Humor Michael Moore

(via FatGrrrl)

Anorexia is the most lethal of all psychiatric disorders, and up to 20% of chronic sufferers will die from their illness.

A new study shows that the mortality rates for other eating disorders (bulimia, EDNOS) are essentially equal to those of anorexia. The authors followed those who presented at an eating disorders clinic for 8 to 25 years, and they found that the crude mortality rate is 4.0% for anorexia, 3.9% for bulimia, and 5.2% for EDNOS.

The authors concluded that:

All-cause standardized mortality ratios were significantly elevated for bulimia nervosa and eating disorder not otherwise specified; suicide standardized mortality ratios were elevated for bulimia nervosa and eating disorder not otherwise specified. Individuals with eating disorder not otherwise specified, which is sometimes viewed as a "less severe" eating disorder, had elevated mortality risks, similar to those found in anorexia nervosa. This study also demonstrated an increased risk of suicide across eating disorder diagnoses.

What this study will mean for DSM-V, I don't know. I do think we need to better define eating disorders, and studies like this will help provide the basis for these definitions.

Exercise dependence is a common feature of eating disorders, anorexia and bulimia alike. However, the ever-astute Cathy pointed out on yesterday's post on exercise bulimia that the term really isn't that well-defined. Some people use the term to mean anyone who exercises to purge calories has exercise bulimia, whether or not they binge and purge or if their weight is "normal." Of course, I had a massive exercise dependence during both the strict AN phases of my disorder, and also for many of the phases in which I was diagnosed with EDNOS. Exercise was a way to rid myself of unwanted calories, either standard daily intake or if I ate more than I thought I should. Out-of-control binges were a much rarer phenomenon for me, so I never had a disorder that would meet the criteria for bulimia.

As the always-fabulous Cindy Bulik pointed out this afternoon on Twitter, there is a clinical difference in the different phenomena that are described under the umbrella of "exercise bulimia." Binge eating + excessive exercise = non-purging bulimia nervosa. Excessive exercise + low weight = anorexia nervosa.

Although I do understand the need to develop different formal definitions for the different disorders in which abuse of exercise is present, the existence od exercise dependence is common to many EDs. Both someone with BN and AN can have exercise dependence, but exercise bulimia doesn't have a formal definition. It is sadly common and underdiagnosed, but take the use of the term "exercise bulimia" with a grain of salt. I wish they would just address exercise addiction, or exercise dependence, or compulsive exercise* and leave it at that. These terms would also capture the significant number of people with EDNOS.

*For what it's worth, I use these terms somewhat interchangably. I know there are probably minor differences in precisely what they mean, but I think they all describe the same thing. English class dismissed.

I found two related stories on exercise bulimia in my news feed today, and although they weren't glaringly inaccurate, there were some aspects I found mighty amusing (but not in a funny way).

The two stories were: Emerging Eating Disorder- Exercise Bulimia, and San Diego Clinic Helps Exercise Bulimics. The first aired on the CBS "Early Show," and the second appeared to be from their San Diego syndicate.

First of all, exercise bulimia isn't an "emerging" disorder. It's a fairly new name for a really old phenomenon. When the first clinical descriptions of anorexia were written in the 1870s, doctors noted the patients' hyperactivity in the face of starvation. Compulsive exercise has long been a feature of eating disorders, and our current cultural obsession to try and burn off excess calories through exercise only feeds this mentality and normalizes the disorder.

Secondly, a link on "related articles" on the first piece linked to an item called "Want to Lose Weight? You Gotta Work Out."

I mean, Holy Irony, Batman!

Also, very 80s graphic they have going there. Yikes.

Thirdly, the text about the San Diego clinic opened with the following: For most of us, hitting the gym is a necessary evil to keep those extra pounds at bay.

*headdesk*

This just confirms that so many people just don't get it. The mentality that exercise is all about weight loss and that more exercise is better because it means more weight loss and dedication only fuels the problem. During my exercise addiction, no one ever asked if I had better things to do than live in my rank sports bra. I get that these articles are meant to be helpful, but they also continue the subtle misinformation about the nature of these disorders.

In the blog and Twitter worlds this past week, there has been quite a kerfuffle over an article written by Sharon Begley in Newsweek titled "Why Psychologists Reject Science." In her editorial, described by opponents as "inflammatory," Begley writes that

many clinicians fail to "use the interventions for which there is the strongest evidence of efficacy" and "give more weight to their personal experiences than to science." As a result, patients have no assurance that their "treatment will be informed by science." Walter Mischel of Columbia University, who wrote an accompanying editorial, is even more scathing. "The disconnect between what clinicians do and what science has discovered is an unconscionable embarrassment," he told me, and there is a "widening gulf between clinical practice and science."

If that isn't the throwing of the gauntlet (or at least a few couch cushions), I don't know what is.

Dr. Katherine Nordal of the American Psychological Association responded to Ms. Begley in the a blog post titled "Taking Issue With Newsweek":

As psychologists, we do embrace our science and research base, but we also understand the importance of the therapeutic relationship to healing and growth. We care about helping our patients improve the overall quality of their lives, and we are not narrowly focused on eliminating one particular symptom (even though getting rid of a symptom is part of improving quality of life.) We combine our understanding of the research with how to best understand the patients who come into our offices with their complicated problems. We work collaboratively to achieve the goals that are important to them.

I'm guessing most of you can guess what I feel about the issue: namely, that Begley has a point, and a very good one at that. After all, by-the-book cognitive behavioral therapy can seem very sterile and clinical. What do worksheets have to do with life? Tell me why I'm like this! What about my feelings?

As one of my favorite new blogs says: F*ck Feelings.

Of course, CBT isn't necessarily sterile, nor is any other evidence-based treatment (EBT). But "evidence-based treatment" is becoming quite the buzzword, and although it's good that people are beginning to recognize the importance of using treatments that we know work, there's no guarantee that therapists who say they use EBT actually use EBT. I've met with a therapist who said she did CBT, and all too soon, it was "tell me about your mother" and "let's work on the real issues," while I continue to exercise for X hours a day and go batty. I suppose I could (and perhaps should) have reminded her that I wasn't lacking insight, I was lacking skills, but I was exhausted and I just stopped going. I'm not above or against helping educate treatment providers, but if I'm going to be doing that much work, she should be paying ME.

(I get that this sounds tremendously arrogant, but I had been desperately searching for help after I moved to DC and found no good providers that had evening/weekend hours, and therapist X was near my office, so I went. I was so beyond frustrated at this point that my patience was essentially gone.)

Dr. Nordal does have some good points, though. It's not easy to translate research into clinical practice. Research studies are very prescribed, there are typically limitations on who can participate in these studies, and adapting the therapies to best help the client is pretty much out of the question. And a good therapist should be able to tweak the evidence-based treatments to best help their clients get better.

But the touchy-feely part of being a therapist seems to be getting in the way of some therapists implementing these evidence-based approaches.

Can people get better without EBTs? Sure. People's symptoms improved when they took snake oil at the beginning of the last century, but we know now that many times, symptoms wax and wane over time. Their improvement had nothing to do with the snake oil and everything to do with the body's immune system kicking in. Is there evidence for psychotherapy? Yes. Is the evidence base as thorough as it is for other therapies? Not exactly.

The Psychotherapy Brown Bag Blog (my other new favorite blog!) had an absolutely brilliant rebuttal to Dr. Nordal that is worth reading in its entirety. This comment, however, captures the essence of the issue:

The argument that science is limited because it does not tell us about each individual is frustrating for multiple reasons. First of all, nobody is saying that it does tell us about all individuals. It tells us, on average, which treatments produce the best effects for a particular diagnosis. Some individuals will fit the norm, others will not. Backers of empirically supported treatments do not argue that everyone will respond the same way to the same treatment. They instead argue that, when making a treatment decision, we should start with the treatment with the most empirical support, regularly assess progress, and adjust our treatment choice as needed if the client does not respond as expected. Certainly, people vary in their values, desired outcomes, personalities, and many other variables that could potentially influence the outcome of treatment. The problem is, we do not have any systematic way of determining who those people are ahead of time, so if we just use our judgment to determine who is unlikely to respond, we are in fact simply guessing and will, on average, provide less effective care, even if we guess correctly on a couple of occasions in which empirical data would have led us astray. Allowing judgment to overrule empirical data is likely to lead to clinicians simply overruling any data that contradict their beliefs while trumpeting data that support their cause.

A blogger for Psychology Today wrote that

students are required to complete multiple research methods and statistics courses, conduct empirical thesis and dissertation research projects among other additional grounding courses and experiences in the science of psychology.

But knowing science isn't the same as understanding the value of science. I could teach someone how to use the biostatistics computer programs I used in grad school, and they could, in theory, "do" science. They could know what kind of tests to run, and how to enter the data, and how to devise the tests. But the numbers are largely meaningless unless you understand how to use them. I've had plenty of therapists who probably know plenty about statistics and research methods, and although that's very useful, it doesn't always translate into better clinical practice.

Ultimately, a Nature editorial summarized it beautifully:

There is a moral imperative to turn the craft of psychology — in danger of falling, Freud-like, out of fashion — into a robust and valued science informed by the best available research and economic evidence.

(I owe so many people thanks for providing these links, that I don't even know where to start. So if I interact with you on Twitter, you have my eternal gratitude!)

I drank it.

Hot.

And whoever helped inspire that, I could kiss you. SO YUMMY.

(Ed's ass is pretty bruised right now. Not that I really feel bad for the SOB.)

Yes, it's that time of year again: the 2nd Annual Health Blogger Awards at Wellsphere. I am going to ask you readers for a simple but ginormous favor- please vote for me! You all did a great job last year and helped me place in the top 50 blogs and rated me the top eating disorder blog.

Voting for me is simple. Go to the Health Blogger Voting page and sign in with your Wellsphere account (it's easy to sign up if you don't have one- all you need is a valid email address and they don't spam!). You can also click on the "Vote Now!" button below. You are welcome to leave a comment, but it's really not necessary.

I've placed the voting logo on the right-hand side of my blog so you can vote whenever you wish (sorry, Mom, you only get one vote!). I will occasionally post reminders as I know many of you use blog readers to keep up with your blogs--I do--and thus won't really see the reminder.

Carrie A. http://www.edbites.com

I was watching NBC earlier today, and there was a preview for the newest season of "The Biggest Loser." The ad copy said something along the lines of "the best of competitive weight loss."

And all I could think was: this has to be one of the most idiotic phrases I've heard.

For what other medical condition (if obesity is, indeed, a real medical condition) do we use competitive treatments? What's next? A chemotherapy competition titled "The Smallest Tumor" where higher and higher doses of chemo are administered in an effort to get the smallest tumor by the end of the show? Will there be oncologists telling the vomiting and balding cancer patients to stop being such babies, and if they want the smallest tumor, they need to suck it up and deal? Or how about a diabetes competition titled "The Lowest Sugar"? You might fall into a coma and die from all that insulin, but it's a small price to pay, right?

There are many theories out there as to what causes eating disorders--perhaps even more theories than there are people to profess them. Some of them are opinion, some of them are based in science, and some of them incorporate both. When I first read of Shan Guisinger's "Adapted to Flee Famine" hypothesis on anorexia, I will admit that I thought the woman was a little cracked. Guisinger hypothesized that the traits so problematic in anorexia nervosa--an ability to go for long periods without eating, hyperactivity--could actually be beneficial during famine, as people could either escape their immediate surroundings to find food, or search longer and wider for food to bring back to the group. Which, from an evolutionary standpoint, did make sense: people with these genes would be more likely to survive a famine, therefore, they would be preserved in the gene pool.

What I didn't get was what a bunch of starving cavepeople had to do with anorexia. Anorexia was, like, about control and wanting to be thin like [insert cover model here]. It wasn't about evolution.

I have, of course, changed my thinking on that a bit. I don't think Guisinger's theory explains everything about anorexia, but it does provide an interesting perspective that is worth listening to. But my motive for posting this stems from an excerpt of her 2003 paper she quoted in a recent letter to the editor that really addresses the resistance many professionals have had in acknowledging the biological basis of anorexia:

Eating disorder specialists have overlooked the adaptive significance of these symptoms because current theories were developed when the pendulum in psychology and psychiatry had swung away from evolutionary explanations. For example, as late as the 1960s researchers had difficulty publishing findings showing that rats have innate abilities to learn to easily associate taste with subsequent nausea because reviewers assumed the rat mind, as well as the human mind, was essentially a tabula rasa at birth. . . . Twentieth century clinicians were not trained to look for evolutionary adaptive processes.

Furthermore, it has been difficult to see a connection between the behavior of starved animals and dieting girls because humans tend to explain behaviors and beliefs in psychological terms. Today’s anorectics often attribute their self-starvation to a desire to be thin, while medieval women with holy anorexia explained the same behaviors with reference to piety. Humans try to make sense of their behavior post hoc, even when it emanates from sub-cortical structures.

(Emphasis mine)

Which really makes me wonder: how much of what we think about anorexia comes from a culturally-evolving script? And can we understand anorexia without that script?

Thoughts?

When I was in DC last weekend, I went to the supermarket with my friend L. so we could buy some stuff to make homemade falafel and dairy-free (vegan) tzaziki sauce (L. has a milk allergy). While we were at the store, I saw that some of the super-expensive bottles of Naked Chai Spiced Apple Juice were on sale. I don't know whether I was just super-thirsty, slightly delusional, or just feeling extravagant and wanted to sink $2.50 on a bottle of juice, but I bought it. I stuck it in L.'s fridge for later that night...which turned into the next day at breakfast...which turned into the next evening...which turned into it's time to leave. More than a little chagrined at purchasing an expensive bottle of juice that I didn't drink, I stuck it in my suitcase for the trip home.

I found an article by the world-famous neuroscientist VS Ramachandran that really got me thinking. The title of the article is "Sexual and food preference in apotemnophilia and anorexia: interactions between 'beliefs' and 'needs' regulated by two-way connections between body image and limbic structures," and most of it is uber-technical and, though interesting, not that relevant to eating disorders.

One paragraph, however is. From near the end of the article, here it is:

Another body image disturbance is anorexia nervosa. A striking feature of this disorder is that counter-intuitively their appetite is often normal, yet the patients refrain from eating because they perceive themselves to be obese (eg when looking in a mirror). We suggest that the primary disorder is not in hypothalamic appetite centers, but, as in apotemnophilia, in the body image representation constructed in the polysensory [superior parietal lobe (SPL)]; that is, the SPL homunculus itself is obese and distorts the perception of one's body. The perceived discrepancy between body image (and a failure to construct an allocentric 'objective' view of the body) leads to acute discomfort that, in turn, reduces long-term food intake behavior rather than, and irrespective of, current appetite. Such a theory would flatly contradict the standard physiological model of food intake being regulated entirely by appetite and satiety. The organism strives for long-term weight change, which can shift long-term food consumption surreptitiously by 're-setting' one's appetite 'thermostat'. Correcting this primary body image disturbance may therefore be the only way to cure the condition which should be seen as a problem in long-term energy regulation rather than a simple appetite problem.

First, some vocabulary. I inserted links with definitions in the above descriptions (probably obvious, since I doubt Dr. Ramachandran would cop to using Wikipedia in a research article). This paragraph is, like the rest of the article, very technical and not written with laypeople like you and I in mind.

Regardless, what Dr. Ramachandran seems to get getting at is that, in anorexia nervosa, sufferers actually perceive their bodies to be 'obese' and restrict their food intake to lose weight to remove all of the flesh and fat that they don't believe is really theirs, similar to how people with body integrity identity disorder (BIID, the more common and speller-friendly name for apotemnophilia) wish to have a limb amputated. To some degree, this makes sense to me.

I have always perceived myself as a very large person. Although I was never tiny or waiflike, I also was well within normal limits on my growth charts. Being teased about my weight only cemented this fact in my brain. I recently told my mom that I had to have been one of the largest girls in my high school class, and she gave me this look like, "What planet have you been living on?"

Even now, I occasionally like to think of placing myself on a spit like the roasted lamb they use to make gyros, and just have some butcher slowly carve away the excess flesh. It doesn't really seem like me. Yes, I get that liposuction won't change a damn thing about me, but to suddenly strip away all of the parts that weren't me and seem so unnecessary wouldn't distress me in the slightest. Suddenly losing a toe would affect me deeply, even aside from things like, you know, pain and blood and balance.

Let me reassure you that I'm not cracked and I know body fat is important and I'm not about to ask the Greek guy down the street if he has a hankering for some gyros. From a rational standpoint, I get that this is pretty strange and not that based in reality. However, this is also how I tend to experience the world. Gaining weight, to me, is like requiring someone with BIID who amputated a limb to wear a prosthetic device.

It's interesting how all of these issues--body image, OCD, anorexia--have all become mixed up into one thing with me. And it's refreshing to see information on body image and eating disorders that's not all about OMG TEH MODELZ!! Do super-skinny models help my whacked-out brain? Not at all. But I think that body image distortion can be far deeper than the pages of Cosmo and Vogue.

Enough about me, though. Tell me what you think!

I apologize for not blogging about this sooner- I've been fighting off some sort of upper respiratory infection since Thursday morning, and my energy has been essentially non-existent. On the upside, I'm feeling tons better, so I suppose that whole "self care" thing does have something going for it.

The conference, "Working Together for Recovery: Families and Professionals as Partners in Eating Disorder Treatment," was this past Monday in Bethesda, MD, and every seat in the ballroom was filled. Many attendees were treatment providers from the greater Washington DC and Baltimore area, but numerous parents also attended. I think this gathering of minds in pursuit of a common goal--better treatment and understanding of eating disorders--should be happening more and more often. I hear a lot about the research/practice divide, which is the difficulties in transitioning research findings into better treatments in a timely manner, and conferences like this are one significant step in the right direction.

Besides getting to see my good friend (and conference organizer) Jane Cawley again, I also finally got to meet Harriet Brown in person, after nearly three years of email correspondence. I also got to meet another mom I had been writing for several months, and it was so wonderful to put names and faces together.

Dr. Walter Kaye spoke first, and a video of his presentation is below. It's just under an hour long, so make some popcorn and enjoy! That's what my parents and I are going to do tomorrow (what can I say? I got my geek tendencies honestly...)

Dr. Daniel Le Grange spoke second, and I would have loved to share his talk in its entirety. However, some of the research results he presented were still under embargo (a research journal's equivalent of a gag order), and if I blogged about it, his paper could be pulled. So, part of his talk will have to wait.

Another study that Dr. Le Grange discussed was published this week in the International Journal of Eating Disorders, titled "Early response to family-based treatment for adolescent anorexia nervosa." In this study, researchers determined that a gain of at least 3 pounds by the fourth session of FBT predicted disease remission by the end of treatment.

One significant difference from previous studies is how the researchers defined remission. Before, remission was defined as the return of regular menstruation and a body weight greater than 85% of ideal. However, there's quite a large gap between "not meeting formal diagnostic criteria for AN" and "recovery." In this paper, however, the researchers defined remission as regular menstruation and a weight greater than 95% of ideal, a much more rigorous definition of recovery and one that I wish more researchers used. Too much ongoing physical and psychiatric damage can occur in that netherworld between no longer officially "anorexic" and not quite recovered.

Le Grange and co. didn't do this study to determine which families to jettison after three weeks--far from it. The goal, says Dr. Le Grange, is to ultimately develop a sort of "FBT Plus," to provide extra support to those families who need it. If, by the end of four sessions, weight isn't increasing, then clinicians know that this family is likely to have more difficulties throughout treatment and should be provided with more clinical and outside support.

Lastly, Harriet Brown spoke of her family's experience using Family-Based Treatment.

You can find copies of all the presenters' slides on the Maudsley Parents conference site above.

With perhaps a little riff from Hillary Clinton, it takes a village to treat an eating disorder. That not only involves the utilization of friends and family to support the sufferer as he/she makes their way through recovery, but it also requires the use of a multidisciplinary treatment team: a physician, a therapist, a dietitian, a psychiatrist, etc. For most people, finding even one treatment provider who is both knowledgeable about eating disorders and reasonably local is the equivalent to hitting the jackpot.

I'm lucky: my dietitian and therapist are in the same office, kind of like one-stop shopping. My psychiatrist is only a 30-minute drive away (45 in traffic, but I schedule my appointments around rush hour as much as possible). When I lived in DC, ironically, it was much more difficult to find treatment providers, since many didn't have evening/weekend hours--a must when you work full-time--and the ones who did made liberal use of the phrase "control issues" in intake sessions.

In the most recent issue of World Psychiatry, Katherine Halmi tackled the issue of "Salient components of a comprehensive service for eating disorders." In the article, Dr. Halmi addressed such topics as the need for better intake and referral services, goals of inpatient treatment, use of step-down programs, types of group therapies to be used, and the overall therapeutic framework of treatment.

Which is all well and good, except for one nagging little detail that Dr. Halmi addresses: there really isn't much evidence for any of these treatments. A study titled "Management of Eating Disorders" that looked at treatments for anorexia, bulimia, and binge eating disorder by the Agency for Healthcare Research and Quality in 2006 found that "No or only weak evidence addresses treatment or outcomes difference for these disorders."

(Note: the link is to the abstract of the research. The link to the full text is at the bottom of the page, but the document is 1,000+ pages. Insomniacs, you can thank me later...)

We need better research on treatment for eating disorders. The latest range of studies on Family Based Treatment for adolescent eating disorders is fantastic, but we also need to find a way to treat adults with AN, and increase the rates of remission and recovery for BN and BED. We have a much better grasp on what we don't know and what we need to know, we now just have to start figuring it out.

Here's something interesting to chew on: Disordered eating in adulthood is associated with reported weight loss attempts in childhood

Researchers found that early childhood weight loss attempts (in children 12 and under) was significantly correlated to both binge eating disorder and unhealthy weight loss behaviors in adulthood.

This got me thinking about the whole chicken and egg dilemma. Did the children who attempted to lose weight at a young age already have dysregulated eating behaviors? Or did the dieting behaviors ultimately result in adult disordered eating? Perhaps it's both, and the dieting further whacked out a slightly dysregulated system.

Regardless, the data have me worried. Considering the increasing number of children who are dieting or otherwise intentionally restricting their food intake, this could mean that the one in 35 American adults with binge eating disorder is only the tip of the iceberg.

I saw an update on Twitter this morning, linking to an article about how the German magazine Brigitte is going to cease using models in favor of "real women." (those two words are used in the deck headline in the Telegraph news article).

This got me thinking: what is a real woman, anyway? Are models, however starved and Photoshopped they might be, not real? Does that mean that models are fake women?

When I read that, I think of this past election when "real Virginia" didn't include any of the DC suburbs where I lived. I may have been a fairly new Virginian, but the state sure took my taxes! Northern Virginia might be more urban and liberal, on average, than the rest of the state, and it might not be what people traditionally thought of as "Virginia" (government stiffs instead of slackjaw yokels, if you really want to dig into stereotypes), but last time I checked, I was a Virginia resident. I was real. My vote counted as much as anyone else's.

So what makes a woman real? Is it like the Skin Horse in the Velveteen Rabbit? Is it the presence of breasts? A uterus? A monthly craving for chocolate? That seems awfully limited. A mastectomy or hysterectomy doesn't dissolve your womanhood- you're still real and you still count. A transgendered person (male-to-female) is a real person, in my eyes. They're not "fake."

What, then, is different about professional models? Their size? I worked with many TB patients who were almost as skinny as I was in the worst of the AN, but for them, it was a microorganism stripping the flesh from their bones rather than a brain disease. They were still women, despite their jutting bones and androgynous figures shrouded by sheets and paper hospital gowns.

Neither my TB patients nor many professional models look like the "average" American woman. And I think it's cool that the magazine is transitioning away from using professional models and using women you're much more likely to encounter on a 3am emergency trip to CVS to buy Midol, Tampax, and a pint of Chubby Hubby. (Not that I have any experience with this...) But even if I didn't encounter some svelte six-foot supermodel at CVS--though luck would have it that I likely would--that doesn't mean she's fake. Just rare.

Our idolization of her shape and size is our problem, not hers. We criticize these models, yet still buy the products they're advertising. It's probably impossible to avoid buying anything advertised by too thin men and women, but we can cut down. And who's to say that Brigitte will use women who look like "average" German women? They probably won't be the ones with zits and excessive facial hair.

I don't know that I have an answer to the question who is a "real" woman. I don't know that there is a single answer (one of the many reasons I avoided philosophy), but I do think that these semantics matter. Professional models aren't a foreign species, and all might not have arrived by their current figures through nature alone. That might make their bodies fake, but it hardly makes them fake.

From today's New York Times:

Study finds calorie postings in restaurants don't change eating habits

So can we take the silly things down already?

(Sorry for the uber-short post. I'm using my phone to post and it's a pain to type more than a few words on my mini keyboard.)

I have been in DC this weekend, and I had some follow-up lab tests (my insurance is only on the East Coast) on Saturday morning. I got an email from my doctor with a summary, and all my labs were normal.

The problem was the text of the summary. Here it is, verbatim and [sic].

Good morninig Ms. Arnold,
Results were all good. Total cholesterol a bit high, but not high enough to require meds. Diet, exercise, weight loss. Take care.

If you are sensitive to swearing, stop reading now...

Has this douchebag even READ my fucking chart?!?

The last time I saw him, during my relapse and before I left DC, he wrote "anorexia nervosa" on my lab slips as my diagnosis--and rightly so. What the FUCK is he doing telling someone with anorexia to LOSE WEIGHT?!? And someone with an exercise addiction to, you know, EXERCISE MORE?

And does he not know anything about high cholesterol in anorexia? As far as he knows, I'm still underweight. He hasn't physically seen me since I've been weight restored.

Maybe it was a mistake and an oversight- doctors are, in fact, human. (I should know- I'm friends with several of 'em) But an oversight like this? Are you fucking kidding me?

He will be getting a letter from me, but later today. When I can use other "f" words like Fred and frankfurter.

When will the insanity stop? Why was this mother criminalized for having two ill children?

Mum's agony as anorexic daughters are taken into care

The 47-year-old mum, a nursery nurse employed by the same council, said: "I asked for some home support but instead of getting the help I needed, my daughters were snatched from me. Anorexia is an illness not a welfare issue."

{snip}

"I took [my oldest daughter] to the doctor straight away. But I'd to fight to get her seen by a specialist. While my youngest daughter was still in hospital, my other daughter was cutting her food down to virtually nothing other than a small handful of cereal."

When her youngest daughter was re-admitted to the hospital, social workers required that the mother turn over care of her two children to the state.

It is the health system that is neglecting this family, not the mother neglecting her children. I can't even imagine how much damage has been done. This is just so, so sad.

Anxiety is not fear, exactly, because fear is focused on something right in front of you, a real and objective danger. It is instead a kind of fear gone wild, a generalized sense of dread about something out there that seems menacing — but that in truth is not menacing, and may not even be out there. If you’re anxious, you find it difficult to talk yourself out of this foreboding; you become trapped in an endless loop of what-ifs.

Avoidant personality traits are common in people with anorexia, and I have to admit that I fit the bill. The Merck Manual describes avoidant personality as this:

People with an avoidant personality are overly sensitive to rejection, and they fear starting relationships or anything new. They have a strong desire for affection and acceptance but avoid intimate relationships and social situations for fear of disappointment and criticism.

Now, I know I don't have a personality disorder, but I definitely have a history of avoiding many social situations and being quite sensitive to rejection. I've found that my confidence in social situations is pretty low, and instead of giving my full attention to the conversation at hand, I'm obsessing about the size of my butt, if there's broccoli in my teeth or toilet paper stuck to my shoe, and thinking up something theoretically interesting to say that probably has nothing to do with what everyone is talking about. Needless to say, this isn't very fun and just reinforces my avoidance of All Things Social.

A new study in Psychological Science found that

People with so-called "avoidant" personalities, who fear intimacy, also tend to shun the kind of social situations that could lead them to forge meaningful relations with others, thus perpetuating a vicious cycle.

In an interview with the BPS Research Digest (also the source of the above quote), the lead authors said that

their findings provided a specific example of an under-explored area - that is, how personality can affect people's lives by influencing the situations they place themselves in. "By sidestepping [socially diagnostic] situations ... avoidant individuals may protect themselves from intimacy, loss of control, and early rejection, but they also forgo the joys and benefits of a reciprocal, trusting relationship," the researchers said, "as well as the benefits that early negative signals can serve in limiting investments into relationships not worthy of such investments."


This seems to be another example of how genes and environment interact, and how trying to separate the two is futile. Environment affects your genes and how they are expressed, and your genes can affect which environments you seek out.