I have much sympathy out there with journalists and reporters, seeing as I am one of them from time to time. Writing on deadline is difficult. Eating disorders are subjects that are fraught with meaning, are not well understood by most people, and are amazingly easy to inadvertently sensationalize. And it is the so-called "meaning" of eating disorders that has me the most tweaked about two stories that I read about today.

One, from CBS titled "Tweens Starving for Perfection," had me annoyed from the title. An eating disorder is NOT ABOUT starving for perfection! It passes along the subtle but absolutely incorrect idea that starving or losing weight will make you perfect--or at least "better." Second of all, I understand very well that an eating disorder can take on meaning in the context of our individual lives. My own experiences have meaning, and so do everyone's, eating disordered or not. But my symptoms (starving, purging, over-exercising) weren't meaningful. They were the result of an illness, not a conscious desire to look better.

I see exactly where people get confused. Hell, I was confused and mired in a cesspool of potential meaning and uninterpreted histories for several years. It was only when I was told, over and over like Robin Williams did to Matt Damon in "Good Will Hunting," that anorexia was a brain disease and these actions were symptoms of an illness. They weren't me trying to express myself on a subconscious level- the only thing they meant was that I had an eating disorder.

Only, humans like to explain things. Think of how many creation stories out there address the question of "Who are we and where did we come from?" Eating disorders are baffling illnesses, both to loved ones and to the sufferer. When I was freaked out by my OCD symptoms in high school, I thought I was being punished for some unknown transgression by the Big Guy in the Sky. It was the only way I could make sense of it. As I went looking for an explanation for my intense fear of food, some of these ideas like "control" and "perfection" made a lot of sense. I freely admit I like to control my world and anyone who has ever met me can attest to my perfectionism. It did kind of make sense.

But my OCD wasn't punishment for a sin, and my anorexic symptoms were largely meaningless. Finding meaning doesn't bring recovery. Finding meaning may be psychically helpful, but I've found it largely useless in getting better. Incorporating your experience into your life story, weaving them into your own personal narrative and giving that some meaning- this is useful. Tremendously so, as I have done it and continue to do it. But that's not the same as saying I was starving for perfection. I was starving because I had anorexia, period.

Many of my complaints about the CBS story can be echoed with respect to this story from ParentsCanada called "Dying to Fit In: Do you know what your tween is not eating?" Schizophrenia is not dying to hear more voices, and depression isn't dying to be sad. Diabetes isn't dying for higher blood sugar, and cancer isn't dying for a larger tumor. An anorexic isn't starving for perfection and they're not dying to fit in. They're just starving and dying. And the sooner we can strip away this false meaning, the better we can get aggressive treatment and nutrition for the people who need it the most.

Raising awareness of eating disorders, especially in age groups where you might not be actively looking for them, is good. But please, try just a little harder. Please. It matters.

(Also see Laura Collins' excellent analysis of the CBS story here)

I took Aria to the vet this morning, which requires a PhD-level subterfuge to corral her into her carrier. I brought the carrier up from the basement last night so that when she saw it and freaked out, there would be plenty of time for her calm back down. Then this morning, I thought I had closed all of the doors to Aria's favorite hiding places so that if she made a run for it, I could retrieve her with relative ease. She did end up under my bed, and secured herself to the carpet in a move that could be summarized as "Attack of the Velcro Kitty." Since neither treats, toys, tuna, or catnip can lure her out in this state, I wedged myself under the bed and gently "persuaded" her claws to transfer their death grip from the carpet to my arm. In she went, and I drove off to the vet's with a frustrated feline yowling in a sonorous baritone that probably would have gained her acceptance into the Mormon Tabernacle Choir.

The poor dear has a cavity in one of her teeth and is going back on Wednesday to have it pulled. She got two vaccines--on in each butt cheek--so Aria has a sore hiney. The vet asked me what Aria ate every day, the brand of wet and dry food, her treats, and how much she eats of each. Aria had gained a little weight in the past year, although I had to up her steroid dose with my move back to the Midwest as it amped up her dermatitis which no doubt caused some of it. The vet gave me some suggestions about her food intake that would help keep Her Royal Fuzziness at optimum health.

Instead of feeding her mainly dry food and supplementing with wet food, she told me to try the other way around (i.e., feed mainly the wet food and only a little bit of the dry, plus the treats she can weasel out of my dad with profound ease). None of this struck me as so interesting that I needed to blog about it. However, what the vet said next was what really lodged itself in my brain.

Wet food is higher-calorie the dry food, so it sounds kind of counter-intuitive that cats will better regulate their weight on higher-calorie wet food. But the wet food is high fat and high protein, while the dry food has a higher percentage of carbs. Cats don't usually eat much in the way of carbohydrates when they're in the wild, so they better metabolise the fats and the proteins and stay healthier.

The geeky side of the crazy cat lady in me thought of this study looking at the relationship between anorexia recovery and dietary energy density and variety. The study found what my fantabulous dietitian has been telling me all these years: eat a wide variety of foods and make sure you eat enough protein and fat!! Like Tina's wonderful experiment, adequate fat and protein intake is important for humans and cats alike.

I worry a lot about feeding Aria because I don't want to project my own food issues onto her, or go completely in the other direction because I fear the thought of someone going without food. It has made me much more sympathetic towards the issues mothers with eating issues (past or present) face in feeding their children. I know that right now, I'm not good at judging how much I need to be eating. I leave that to my dietitian and my parents because, like I said, I don't know. So if I'm not confident in feeding myself, how can I be confident in feeding my (fur)child? Which is why I think research like Nurture at UNC Chapel Hill's ED Program is so important. Hopefully it will give women the knowledge and confidence they need to make good decisions for themselves and their children.

Besides my copious packages of Ensure Plus that I pick up at the grocery store now, I guess I'll have to add some more tuna for Aria.

My brain feels like mush. The cognitive affects of my ED are some of the most annoying for me to face. The physical stuff, I can usually manage. But not being able to think straight, or to read and feel the text somehow evaporate in the short distance between my eyes and my brain--this drives me nuts. Even the simplest of tasks, whether it's brushing my teeth or crocheting, leaves me feeling like this little guy here:



So what do you think a complete geek like me does when she gets frustrated and exhausted? That's right- she turns to PubMed.

I found this study on the reversal of cognitive markers of anorexia with weight restoration rather fascinating for both my current state of mind and current state of body. Granted, the authors studied adolescents on their first presentation for AN treatment, neither of which are true for me anymore. That being said, I'm not entirely sure that these reversals would have been different for longer-term patients, although they may have taken longer.

Like Ancel Keys found in the Minnesota Starvation Study, adolescents in the acute phase of AN showed slower sensorimotor responses to stimuli and were more affected by others' interference. Working memory, however, was not impaired. After weight restoration, the adolescents' performance on the first two tasks were significantly improved, and "relative to controls, they were significantly faster on attention and executive function tasks, exhibited superior verbal fluency, working memory, and a significantly superior ability to inhibit well-learnt responses."

So although eating right now is making me want to bash my head in (metaphorically speaking- my head is pretty darn hard and I would fear more for the wall than my skull), one of the advantages to eating is the reassurance that my brain will work better. If only I could get an off switch for the silly thing...

What helps you along in recovery? It doesn't need to be existential or even particularly significant, just what you cling to when the going gets tough.

My new friend Krystal emailed these spectacular words of wisdom to me yesterday, and it was so lovely I had to share it with you:

“You will receive a body. You may like it or hate it, but it will be yours for the entire period this time around.”

Every time someone says to me, "I'll give you 10 of mine" (when I say I want to gain), every time you are saying to yourself "I look like a boy," every time you feel weak for having wrinkles, or hips...know this: you are enough....you ARE your body. It's not yours to possess and whip into shape or manage. It is beautiful and broken and the only thing that in the world that does not leave you.

Honor it...don't just accept it. Honor it.

This sucks. I mean, this really really sucks.

I hate that I have to eat (and eat A LOT!) when I don't want to.

I hate that I hardly leave the house.

I hate that all I want to do is go for a run (yes, I have exercise issues and also see previous) and I'm not allowed.

I hate that I'm home from my job and my friends in DC and stuck in the Midwest.

I hate that I'm nearly 30 and have trouble feeding myself properly.

I hate that everyone watches me while I eat so I don't hide food.

I hate that people monitor my bathroom visits.

I hate that I eat six times a day and it seems all I do is eat.

I hate that I'm more obsessed with food now than I was before I started eating again.

I hate that I can feel my body doubling in size at every meal or snack.

I hate that I hardly have any privacy.

I hate that I'm such a burden on my family.

I hate that I have to face food every single day for the rest of my life and I'd really rather not, at least not unless it was apples and lettuce and nothing else.

But you know what I really really hate?

Knowing that this is necessary.

Knowing that I would go right back to the AN if given half a chance.

Knowing that yes, I am almost 30, and no, I haven't learned how to feed myself properly.

Knowing that the only way out is through.

(Sorry if this sounds like adolescent melodrama- I'm not going off the deep end, just deeply frustrated and a little pissed off at everything right now.)

I stumbled across a news article about how 'Phantom fat' can linger after weight loss when I was on Twitter (do you follow me on Twitter? Click here to start following ED Bites!) and I was struck by how much this seemed to describe what was going on in eating disorders. The article quoted a women who had lost a significant amount of weight over the past two years, and how

every morning when she looks in the mirror while getting ready for the day, she sees her former, heavier self. “My brain says, ‘Yep, still fat.’”

“It's been really hard to change my self-image,” says Hicks, 37, of Chesapeake, Va. “I still feel like I'm this enormous person who takes up tons of space.”

When I was in residential treatment the last time (in 2006), I groused about how fat I felt, how skinny all the other girls were, etc, etc. Standard AN kvetching and bitching. Still, the dietitian I was talking to made a good point: I had gained weight. Okay, not much, but I had, and I knew it and that's in part what I was there to do. My body was heavier than it had been. And considering I had been underweight for at least a solid year by the time I started treatment again (though my lowest weight was back in 2001), some of my physical feelings of fatness were not strictly ED-driven, but also might happen to anyone gaining weight. Or, in the context of the article, people losing weight as well.

I was oddly reminded of this conversation about a year ago, when I was riding the commuter train from DC to Baltimore, as I headed home from my summer internship. There was a 16-year-old boy (I'm guessing) and his family, and he was almost literally all limbs. He carried himself a bit awkwardly and--here's the really interesting bit--he kept banging his head against the overhead rack. He made a joke about his growth spurt, and it hit me: his perception of his body (known formally as proprioception) hadn't yet caught up with his new height! Cammy did a wonderful post about something similar right after this happened, which kind of cemented the incident in my head.

It makes sense that there would be a link between body image and proprioception, and researchers have found previously that the body image distortions in people with anorexia was linked to abnormal amygdala functioning and the fear response. So it makes sense that significant fluctuations in weight would be linked to both body image and proprioception, especially in people with a history of dieting like many of the women featured in the article.

“People who were formerly overweight often still carry that internal image, perception, with them,” says Elayne Daniels, a psychologist in Canton, Mass., who specializes in body-image issues. “They literally feel as if they’re in a large body still.”

Daniels and other experts suspect this may happen because the brain hasn’t “caught up” with the new, leaner body, particularly for people who were obese for many years and then experienced rapid weight loss.

“Body image is a lot harder to change than the actual physical body is,” Daniels says.

Amen to that, sister.

Psychologist Joshua Hrabosky found that women who were currently "overweight" or formerly "overweight" had a "dysfunctional appearance investment" and were more preccupied with weight that women who were never "overweight."

The findings suggest that “people who undergo major weight loss may experience improvements in satisfaction in appearance, though still not necessarily as much as someone who was never overweight,” Hrabosky explains. “But they are also still more invested or preoccupied with appearance than someone who was never overweight.”

It does make me wonder what dieting and food intake might have to do with weight perception and body image, as even healthy men in the Minnesota Starvation Study complained of "feeling fat" during the rehabilitation phase.

But the article raises some really good points about the psychology, too. When you've thought of yourself as fat for most of your life, it's really hard to change that thinking no matter how much weight you've lost or how much you understand the futility of dieting. I'm curious to see how this research will affect thinking on the body image distortions in eating disorders. We shall see.

I know I write a lot on biology, and its importance in relation to eating disorders. Part of this is because I strongly believe in the importance of biology, and part of this is that I feel the cultural issues surrounding EDs get plenty of coverage already, so I tend to leave them alone.

But there was some interesting new research that looked at the relationship between negative mood, body image, and EDs in two different cultures. The authors compared groups of anorexic and healthy women from both France and Poland, and looked at how symptoms and duration of depression and anxiety affected both body image and eating disorder symptoms. Even considering that both groups of women were from Europe (though one from behind the Iron Curtain and one, well, not), the researchers still found differences between the two groups.

Both groups of anorexic women had higher anxiety and depression than healthy women, but the Polish anorexics had higher levels of depression than French anorexics. Depression in the anorexic Polish women increased both with age and Body Mass Index, but had no relationship to how long the women had been ill.

In the group of Polish women, high levels of anxiety corresponded to high levels of maturity fears and interoceptive awareness (i.e., the physical state of your body, like hunger, thirst, etc). In the French women, however, high levels of depression corresponded to higher levels of bulimia, ineffectiveness, interpersonal distrust, interoceptive awareness and maturity fears.

I'm not discounting the importance or relevance of the specific correlations the authors found, but that's not what I found really interesting. What this study says to me is that symptoms of anxiety and depression are important in the development of eating disorders no matter what culture you're from. But the details of this relationship can vary depending on your environment. Which just makes a whole lot of sense: people with EDs aren't (oh, the pun!) cookie-cutter people. Although there are remarkable similarities in people suffering from EDs, there are lots of differences, too.

Here's a bit of a confession: I have a hard time believing people like me. Why? There are the obvious self-esteem issues, but there's also my whacked-out interpretations of what other people must be thinking about me. When I'm talking, are they bored or do they just have a really full bladder? Is it a bad day or something I said? Are they offended or just not amused? Are they mad at me? Are they? Are they?

I usually conclude yes, they are mad at me, and then go about wracking my brain to determine what I did that could have caused them to hate me (note that being mad at me automatically translates into "you hate me" which is a cognitive distortion in and of itself). When I can't find anything, I assume it's just, well, me.

As I interact with people, I tend to hyper-interpret everything. An arched eyebrow becomes a stiletto through the heart. The flick of a wrist can toss cold water down my back. This isn't to say that I'm always right--nor that I'm always wrong, seeing as I've pissed off a few people in my time--just that I'm always aware, always looking for meaning.

So when I first read of the similarities between anorexia and autism, I arched an eyebrow of my own. My cousin's son is autistic, and though behavioral therapies have made a world of difference, he still has problems understanding other people's emotions, even just understanding that other people have emotions. Clearly, I didn't have this problem. I was almost too aware of what others might be thinking and feeling.

But the more I think about it, the more I realize that they are just (oh dear) mirror images of each other. Both my second cousin and I have difficulties in recognizing emotion. Whereas he doesn't interpret enough, I seem to interpret too much. And this issue only becomes worse when I'm malnourished and starving.

Previous research had shown that women with anorexia had difficulties in interpreting emotional faces. A recent study by Janet Treasure and colleagues found that women hospitalized for anorexia had difficulties in both recognizing and regulating emotions. The authors concluded that although they don't know whether this is a side effect of starvation,

the acceptability of emotions and recognition of emotions are important factors, so specifically practising emotion recognition and examining the function of emotions might be useful treatment targets. Building skills in emotion functioning may enable the client to feel more confident about social interaction and reduce isolation. It might also be useful to involve the family to build a shared understanding of emotional functioning.

It's not a secret that I love science and in particular, biology. I majored in biochemistry in college and have a master's in epidemiology and infectious disease. I have been reading "Microcosm: E. coli and the new science of life" by Carl Zimmer, and so I didn't expect to run across anything that reminded me of eating disorders.

But if there's one thing I love as much as biology, it's metaphors. Or, in this case, finding parallels and expectations in the most unusual of places.

Many of the complaints I've heard about the importance of biology in eating disorders has less to do about the evidence and more to do with the simple fact that people think it's deterministic and depressing. If it's biology, there's nothing we can do. We were destined to become ill, and we're always going to BE ill because it's in our genes. To me, however, biology gives me a road map out of my illness, however vague and imprecise it is (think Columbus and Magellan, not GPS). I can't escape my biology, but I can learn to live with it.

Another complaint is that if eating disorders are genetically-based, then why don't all members of a family have them. Because not everyone's genes will be turned on at the right time to create a disorder. Environment matters, and it matters a lot.

Which is where one of my latest reads comes in. The actual passage is a little long, but I've tried to edit out the parts that didn't add to the ultimate point I'm trying to make.

We are not merely the output of software written in a programming code of DNA. As we develop in the womb, our genes interact with signals from our mothers. The environment continues to influence those genes in unpredictable ways after birth. The food we eat, the air we breathe, the traumas and joys and boredom of childhood, and all the rest have an influence on which genes become active...

Surely E. coli must be all nature and no nurture. A colony descended from a single ancestor is just a billion genetically identical cousins, their behavior all run through the same genetic circuits. E. coli is just a single cell, after all, not a body made of a trillion cells that take years to develop. E. coli doesn't grow up going to private school or searching for food on a garbage dump. It doesn't wonder whether it might like snails for dinner. It's just a bag of molecules. If it is genetically identical to another E. coli, then the two of them will live identical lives.

This may all sound plausible, but it is far from the truth. A colony of genetically identical E. coli is, in fact, a mob of individuals. Under identical conditions, they will behave in different ways...

There's much to be learned about E. coli by thinking of it as a machine with circuitry that follows the fundamental rules of engineering. But only up to a point. Two Boeing 777s that are in equally good working order should behave in precisely the same way. Yet if they were like E. coli, one might turn south when the other turned north.

The difference between E. coli and the planes lies in the stuff from which they are made. Unlike wires and transistors, E. coli's molecules are floppy, twitchy, and unpredictable. They work in fits and starts. In a plane, electrons stream in a steady flow through its circuits, but the molecules in E. coli jostle and wander...[This jostling] can produce long-term differences between genetically identical bacteria...Two genetically identical E. coli can respond differently to the same level of lactose because they have different histories...

At the very least, E. coli's individuality should be a warning to those who would put human nature down to any sort of simple genetic determinism. Living things are more than just programs run by genetic software. Even in minuscule microbes, the same genes and the same genetic network can lead to different fates.

Considering that I spent several years studying E. coli in college, I find these things fascinating. If we consider something like bacteria to be "simple," or at least simpler, with significantly fewer genes and much smaller than even a single one of our cells, and they are markedly affected by their environments, imagine how the environment acts on us. In biology, nothing is simple and easy.

Most of my readers know by now that I don't dispute the fact that eating disorders are biologically-based mental illnesses. They clearly have a biological component, although this isn't entirely without controversy. Research has yet to tease out exactly what these components are and how they interact with both each other and with the world at large. But the latest science points to a strong biological basis for eating disorders.

I recently read a fantastic review article by none other than my "homeboy" Walter Kaye* called The Neurobiology of Anorexia and Bulimia Nervosa, the full text of which is now freely available, understandable, and well worth the read. A few lines that lodged in my head:

Because AN and BN present most often during adolescence in women, they are often theorized to be caused by cultural pressures for thinness since dieting and the pursuit of thinness are common in industrialized countries. Still, AN and BN affect only an estimated 0.3% to 0.7% and 1.5% to 2.5%, respectively, of females in the general population. This disparity between the high prevalence of pressures for thinness and the low prevalence of eating disorders (EDs), combined with clear evidence of AN occurring at least several centuries ago, the stereotypic presentation, substantial heritability, and developmentally specific age-of-onset distribution, underscores the possibility of contributing biological vulnerabilities...Twin studies of AN and BN suggest there is approximately a 50 to 80% genetic contribution to liability accounted for by additive genetic factors. These heritability estimates are similar to those found in schizophrenia and bipolar disorder, suggesting that AN and BN may be as genetically-influenced as disorders traditionally viewed as biological in nature.

Additive genetic factors are pretty much what they sound like: several independent genes that together influence the likelihood of developing an eating disorder. The more factors, the higher the risk. The math is far more subtle and complicated than that, but that's essentially how it works.

In a recent article in Time magazine (featuring none other than our lovely Laura Collins) about the relationship between anorexia and autism (I've blogged about the subject here), Dr. Kaye said these wonderful words:

"[Anorexia is] highly heritable, it runs in families, and it's clear now that it's affected by a cluster of [early life] vulnerabilities like anxiety and perfectionism. If you don't have those vulnerabilities, you are very unlikely to develop anorexia," says Dr. Walter Kaye, director of the eating-disorders program at the University of California, San Diego..."I think that anorexia is as biological as autism. It's just 20 years behind in terms of research."

A 2005 article titled Anorexia could be caused by brain dysfunction quoted Bryan Lask who explained the biological predisposition as follows:

"The biological cause has been under-emphasised and the socio-cultural pressures have been over-emphasised. There has to be a biological contribution otherwise everyone would be anorexic given the socio-cultural pressures in our society," he said. "I am not saying people are born anorexic any more than they are born asthmatic or diabetic. But I am saying some people are born with a genetic pre-disposition to anorexia which makes it more likely to develop. If you live in a society which promotes thinness as the ideal then you are more likely to develop anorexia if you have the biological predisposition."

Biology isn't simple, though, and no disease--no characteristic, no phenotype--is entirely biological. Environment always plays a role, like Lask said. I have a longer post on this tomorrow that will be full of geeky goodness.

*I got to tell him that I called him my "homeboy" at last year's NEDA conference, which was a combination of funny and embarrassing- for both of us!

My therapist gave me a small card last week week, that contained this small magnet and a little message:

Today, I had the great fortune of reading two great pieces from Australia on eating disorders.

The first is an article titled Anorexia's Lifelong Legacy from the Sydney Morning-Herald, about how eating disorder diagnoses are missed in many boys, simply because pediatricians aren't looking for them, and don't think that males get eating disorders. Because proper, quick diagnosis has a large impact on disease outcome, these kinds of stories are very important. Besides covering this timely and important topic, the article did so in a scientifically accurate way. Some of my favorite quotes:

"When kids are starved, their brains shrink, they're more likely to get depressed and anxious, their thinking slows down and memory falters," Madden says. "This affects their relationships with their friends. The effects can be reversed with re-feeding, but not always."

These serious complications can be prevented if children at risk are picked up early. "If children get the right treatment early, 70 to 80 per cent get well in 12 months and 90 per cent are better in five years. This is much better than in adults where the recovery rate at five years is less than 50 per cent," Madden says.

And

Whether an eating disorder can take hold and thrive seems to rest in the balance of risk and protective factors that a person experiences. In the last few decades, the increasing number of risk factors experienced by children - such as stress, anxiety, dieting, body image worries, and exposure to media images and messages that equate fat loss with happiness - may be creating an unhealthy tipping point.

And

The media comes under fire, not as the cause of eating disorders, but as a potent "enabler" of fat phobia, body discontent and restrictive eating in young people...Kohn agrees that children are being influenced by anti-obesity messages. "Vulnerable children hear them in the wrong way and take them to the extreme. Then a physiological mechanism kicks in, reinforcing the behaviour. Eating less and losing weight dampens down the serotonergic mechanism in our brain that processes emotional responses. This makes the children feel better, calmer, less reactive. Their behaviour improves and they get positive feedback, locking in the dieting behaviour."

I wish more articles on anorexia were like this, chock-full of the latest research and entirely lacking in sensationalism and parent- and sufferer-blaming.

The other good read from Down Under is the book "My Kid is Back: Empowering Parents to Beat Anorexia Nervosa" by June Alexander. The book arrived in the mail on Monday, and I've been steadily chipping away at it ever since. As the title suggests, it is more intended for parents than sufferers, and contains the stories of several families who have helped their children conquer their eating disorder. Filled with wisdom and hope, it will be a great read for people needing encouragement along this long journey of recovery. It officially arrives for sale in the US in September, and you can pre-order your copy from Amazon.

Enjoy your Down Under reads- I know I am! Now, about that duck-billed platypus...

A is for aspartame, the only sweet allowed.
B is for broccoli, the ultimate safe food.
C is for calorie, which you always count.
D is for diet, that you're always on.
E is for elliptical machine, your BFF.
F is for fat, something you always feel.
G is for garbage, where your food usually ends up.
H is for happy, a feeling you can't remember.
I is for identity, what the eating disorder is.
J is for jealousy, that other women seem to feel.
K is for potassium, always low.
L is for losing weight, your favorite activity.
M is for mother, the cause of anorexia.
N is for nobody, who can penetrate your mindset.
O is for obsession, consuming your every second.
P is for perfection, as you accept nothing less.
Q is for quarter-pound, either too much or too little.
R is for recovery, that seems so far off.
S is for sleep, which perpetually eludes you.
T is for therapy, where your money goes.
U is for U-turn, that everyone hope's you'll make.
V is for vigilance, exercise this or you'll get fat.
W is for weight, of which you can never lose enough.
X is for X chromosome, and it is assumed you have two.
Y is for yourself, someone you no longer know.
Z is for zero, the size you strive to be.

(Sorry for the bit of a downer, but it fits my mood right now. I'm not sure how tongue-in-cheek it's meant to be.)

Sometimes, this world just makes me wonder. Several times this past week (on TV, in the grocery store, and on a menu), I have seen "guilt-free" products advertised. You know "pasta without the guilt" or "this type of meat is super low-fat, so you can eat it without guilt!"

There are many reasons I don't like these types of ads (because...we're supposed to feel guilty when we eat?) but right now, they're really frosting my (full fat) cookies because I hate it when my disordered thinking seems normal. Granted, the few items I would allow myself to eat in minimal amounts without guilt were both paltry and pathetic, but still. It's the same idea. I felt guilty if I ate anything besides these four items at the wrong time or in the wrong amounts. These foods had some sort of magical air about them, that they were sacrosanct, and I could never go wrong eating them.

And here I go, back into the "real world," trying to recover again, only to learn, again, that most of the world is really screwed up about eating. It would be SO MUCH EASIER if I could just figure out if my thoughts were being driven by the eating disorder, or if they were my own thoughts. And when you can almost reliably go into a restaurant or grocery store and find little slogans that could have sprung from your eating disordered brain, well, it's screwing with me.

I saw an ad for milk yesterday that trumpeted the benefits of low-fat and fat-free milk. Um, I'm drinking whole milk for the foreseeable future, and thanks Milk Council, for the reminder that I'm a freak. Yes, I know, most people don't need to regain X pounds, but still. And then a little TV segment for making a blueberry smoothie. I love blueberries, I love smoothies, so I watched to see what the lady was doing. She used fat-free yogurt and fat-free milk- "all of the nutrients, none of the fat!" she chirped. I'm sorry, but my dietitian has been telling me for years that fat is a necessary part of the diet. Even with my (relatively) short relapse, the lack of fat has led to colorful bruises all over my knees, brittle nails, and really dry hair. And last time I checked (a decade ago in biochem and five seconds ago on Google), fat was still a nutrient. So skim milk doesn't have quite the same nutrients as whole milk. My parents drink skim--there's a hella lotta milk in the house right now--and I don't necessarily care, but they're not the same, and one is not better than the other.

Maybe I'm over-reacting. Maybe I'm over-sensitive. Both are probably true. But it irritates me. It's hard enough to recognize ED thinking within the confines of my own skull because I've heard it for so long and bought into it for so long and this damn disease distorts reality so well that it sure seems real to me. So when our whole freaking culture buys into the idea--lock, stock, and barrel--that low fat is better than "regular," that we should feel guilty for not eating the lowest calorie item in the store or on the menu, that we should download the latest iPhone app to keep track of our food intake, I can't help but feel betrayed. I know "they" aren't doing it specifically to piss me off, but it still feels incredibly unfair.

When I started trying to sort my way through the OCD that dogged me through high school, I had a fair amount of certainty that circling the block because you thought you'd hit a duck, or scrubbing your hands with Clorox because you were petrified that you would give someone a fatal disease were abnormal behaviors. I knew they were screwy even if in the moment I felt compelled to do my rituals. I also have some amount of awareness that a steady diet of sugar-free yogurt, apples, and lettuce is also screwy (even if in the moment I felt compelled to eat them and then frenetically exercise those calories off), but so much of the ED mindset seems so normal. Parents don't necessarily worry at first when their children kvetch about their stomachs and butts, or they don't want mayo on their turkey sandwich anymore because those "hidden fats" make a huge difference, simply because it's so normal. And most kids who say and do these things won't develop eating disorders--but some will.

When you're fighting your way out of a seriously messed up value system, only to find that your values are simply extreme versions of what the vast majority of people are thinking, you have to stop and ask: whose disorder is it anyway?

For most people, anorexia nervosa and binge eating seem pretty much as opposite as you can get: one involves extreme food denial, and one involves extreme food consumption. There also appear to be preexisting biochemical differences between the two disorders. On the other hand, all types of eating disorders show a correlation with mood and anxiety disorders, and tend to overlap with numerous addictive disorders as well.

Several years ago, Christopher Fairburn proposed a transdiagnostic model of eating disorders, which essentially states that in EDs "shared, but distinctive, clinical features tend to be maintained by similar psychopathological processes" that include low self-esteem, interpersonal difficulties, mood intolerance, and perfectionism. Supporting this theory is the high degree of "switching" from one ED to another, a process formally known as diagnostic migration.

Yet the issue remains: how can two disorders that appear to be almost (ahem) mirror images of each other be the same and yet be different?

In a recent article titled "Affect, cognition, awareness and behavior in eating disorders. Comparison between obesity and anorexia nervosa," a Hungarian psychiatrist looked at differences between AN and obesity. Now, obesity isn't a mental health disorder, nor should it be one; however, binge eating disorder is very real. Since the original text is in Hungarian (with only an English abstract), I don't know whether this is a translation mistake or whether the author is trying to assert that obesity is a mental illness. For the sake of MY arguments and thinking, however, I'm going to think of "obesity" in this article as BED since this appears what the author really should be getting at.

Cserjési makes a cogent point in the abstract:

"Previous studies suggested that emotional disturbances (depression, anxiety and alexithymia), cognitive impairments and distortion of body image are frequently associated with anorexia nervosa. However, obesity is mostly regarded as a weight management problem."

Which is quite true. Although many still view anorexia as a choice and a diet gone too far, there is a slow shift to seeing it as a real mental illness. BED is sadly even further behind.

The results of this study, however, are far more intruiging.

Neuropsychological tasks showed common deficit in attention capacity. Obese patients, both children and adult showed impaired shifting capacity and mental rigidity associated with frontal lobe based executive functions. Obese patients had difficulty in categorizing negative emotions (sadness), anorexic patients in treating happy faces. Obese group evaluated positively the overweight body on the implicit level. Anorexic group did not evaluate positively the ultra thin body. Conclusion: our results suggest that restrictive anorexia nervosa has several common features with anxiety disorder, while obesity can be associated most probably with addictive pathologies.

Impaired set shifting (also called cognitive inflexibility) is now being considered as one of the trademarks of anorexia, as is the relationship between anorexia and anxiety disorders, especially OCD. And Nora Volkow's work out of the National Institute on Drug Abuse has been examining the similarities between obesity, compulsive or binge eating and addiction. (h/t Tiptoe for the last link)

This hasn't totally resolved the issue, as there is plenty of evidence that anorexia shares similarities with addiction and that anxiety is a problem in binge eating. But examining these disorders for their similarities and differences not just in behavior but in underlying neuropsychology will hopefully tell us more about what is really going on and what really causes eating disorders.

Most news stories on eating disorders fail to make the distinction between what causes an eating disorder and what triggers the disorder. They're two very different things. According to the latest research and thinking, eating disorders are caused by alterations in brain chemistry that register anxiety and mood, hunger and fullness. That, right there, is pretty much the root cause, though I could potentially be burned at the stake as a heretic for saying so.

I'm not a freaky reductionist, though. Environment is important, as environment triggers and maintains the disorder. Environment starts during fetal development and never stops. Your environment could be your season of birth, the magazines you read, the TV shows you watched, the food you ate, the friends you had. Although fully separating genetics and environment is impossible, I am willing to say that the cause of an eating disorder isn't the same as the trigger.

Which is why I read this article with more than a little dismay: 'Crisis In Masculinity' Leads To Eating Disorders In Straight Men

I understand that men have far different experiences of eating disorders than women, and that these stories are worth paying attention to. We can (and should!) learn from them. Although a man's experience of an eating disorder is going to be different, the illness is the same. Same cause, but there could be different triggers.

A eating disorder isn't about a crisis of masculinity or femininity. It's a disorder that started with malnutrition and snowballed out of control. It's not a choice, it's not a way to resolve problems or existential issues. The article says the following:

Images of skeletal models or men with 'six-packs', plus a plethora of choices now open to men, is at the root of body dissatisfaction, Dr [John] Morgan said.

"To be a young man is our society is a difficult thing. What you do and who you are is less straightforward. Women were challenged decades ago to consider which of the many different social roles they adopted. Now men are having to respond to the choices that society gives them.

"Suddenly younger straight men have similar pressures to gay men and women. There is a crisis of masculinity in our society. They are given all these roles and to simply decide to manipulate your body is a nice easy solution to all the complexities of life."

What part of an eating disorder is a "simple decision"? Perhaps the initial weight loss, but the actual disorder is far more complex and this kind of thinking does sufferers a great disservice. Body image woes can certainly trigger an eating disorder, and there is some evidence to suggest that people with eating disorders perceive their own bodies differently than they perceive other people's bodies. And being a young person is almost always a difficult task, and societal pressures don't help, but they don't ultimately cause an eating disorder in women or in men.

If you hear hooves, the saying goes, think horses not zebras. The advice for doctors encourages them to think of simple pneumonia with an unrelenting, raspy cough in February rather than an exotic fungal infection from the Seychelles. For a therapist, it might mean that (as Freud put it) sometimes a cigar really is just a cigar. It's standard, fairly solid advice. Rule out the obvious before you start chasing something more obscure.

The problem is that hooves and horses don't always go together. Just because you see a horse doesn't mean you're going to hear hooves.

The Metaphor Queen will explain. An article on EmpowHer posited that the number one reason for developing an eating disorder was a "relentless boundary invasion on every level." For this metaphor, let's call the eating disorder the horse (remember Mr. Ed the talking horse?) and any possible "boundary invasions" the hooves. Also for the sake of this metaphor, let's say that we know the horse is there, we know that the person has an eating disorder, but we're still listening for the hooves.

The problem with such arguments--beyond the fact that they have nothing to do with the latest science--is that they make the facts fit the theory. For the metaphor, you automatically hear hooves when you see a horse, even if the horse is standing still. Most people have had boundary invasions. The idea of a "boundary invasion" is fairly nebulous, and different people will have different standards as to what is a relentless boundary invasion. I'm quite a private person, despite my public blogging, so I have a fairly low tolerance for people poking around in my stuff. But if you look hard enough, most people will have had a boundary invasion, whether someone read their diary, they were touched inappropriately, or their mother insisted that her child let her know where they were at all hours.

Yet if most people have had boundary invasions, why don't more people have eating disorders? If there is a deafening cavalcade of hooves, why do we only see a few horses?

Having worked with an old-school psychotherapist for several years, a PhD psychologist who was quite probably the most well-known ED therapist in my area at the time, I know a bit about straining to hear hooves just because you see a horse. I must have sifted through every childhood memory, trying to figure out what might have caused my eating disorder. Mostly, we focused on my mom. The two of us were too enmeshed. I was afraid of growing up. She was afraid of letting go. I was symbolically rejecting her by literally rejecting food.

Maybe this was partially true- I don't know. But it ignored several pertinent facts: when your kid is sick with a deadly illness, of course you're afraid of letting go. I wasn't afraid of doing my own thing until I got sick. I had no explanation for why I couldn't eat, I just didn't want to, and that had nothing to do with my mother.

We had the horse, obviously, and we kept thinking we were hearing hooves. We wasted years listening for hooves, while that damn horse stayed in the stable and I had to shovel out the shit. It wasn't until I started seeing my current therapist almost three years ago that I began to try and move the horse out of the stable. That even if there were hooves, I was still stuck mucking out the stable, which was the real problem. NOT the hooves.

An eating disorder diagnosis says nothing about the quality (or lack thereof) of parenting. Nothing. Period. Full stop.

My other real problem with this type of antiquated, outdated thinking is that it is not based on the latest scientific understanding of eating disorders. The article didn't mention the strong genetic basis for all eating disorders. It didn't mention any of the brain imaging studies or rat models of excessive exercise. It didn't mention serotonin or dopamine or leptin or ghrelin.

The truth is, we don't know exactly what causes eating disorders, but we do know that bad parenting, skinny models, and "boundary invasions" isn't it. And it's time we moved on from these ideas onto something that actually helps sufferers and their families.

I wanna dance the tango with chance
I wanna ride on the wire
Cos nothing gets done with dust in your gun
And nobody respects a liar

So goodbye for a while I'm off to explore
Every boundary and every door
Yeah I'm going north

Before I disconnect my laptop and stuff it in my messenger bag, before I stuff the cat into her carrier, before I remove my supplements from the freezer, I wanted to say a temporary farewell. I am, as the song says, "goin' north."

I wanna know where children would go
If they never learnt to be cool
Cos nothing's achieved when pushed up a sleeve
Till nobody thinks you're a fool

So goodbye for a while I'm out to learn more
About who I really was before
Yeah I'm going north

I'm going to miss this area and miss my friends and miss the hopes and dreams that I had. I'm going to miss my balcony and my fireplace. I'm going to miss the doggies in my apartment complex, from the overgrown black lab puppy who licked my feet yesterday to the 6 foot 4 guy with dreadlocks down the hall and his toy poodle (no joke).

Up where the hunted hide with ease
Under the arms of eye-less trees
Up where the answers fall like leaves
Oh and your love is all I need
Yeah I'm going north

But north has its own upsides- my therapist and my family. So I'm going north and I'm going home.

"Going North"
--Missy Higgins

I'm lucky- I'm related to some pretty cool people (Hi, Mom! Hi, Dad! Hi, Aria!). I'm also related to some douchebags, but let's focus on the positives, shall we? But I'm also lucky because I have some pretty awesome friends in my life, friends who I will miss dearly when I am back in Michigan. Friends who I didn't know before I moved to the area and now can't imagine my life without.

Today, I said a temporary farewell to my good friend L and also Laura Collins, who met my mom and I for lattes at Borders. Both L and Laura came bearing gifts, because they're cool like that. L made me a set of door hangers, two of which I've shown here:


My mom said we may as well hang the Aria one on the front door since the fuzzmuffin runs the entire house. 'Tis true.

Laura bought my mom and I some kids' books to inspire us during refeeding, and her and her family (Olympia and her son Elijah who knows me solely as Aria's mommy- the cat approves) made me my very own magic plate!


How cool is that? The lighting isn't the greatest but I didn't have time to fuss with my camera settings and my photo editor.

I'm really going to miss my two L friends. Getting back to them and the shreds of a life I had been building before the AN--that house of cards called "recovery"--came crashing down on me is one of my goals at this point.

I apologize for the lack of posts recently- I've been beyond exhausted trying to box up a lot of the stuff in my apartment and get ready to move back to the Midwest.

My parents arrived on Friday night, and my first thought was: just kidding. I'm okay, really I am. I can't shake the feeling that I'm making a big deal out of nothing, even though all evidence points to the contrary. My therapist dropped the f-bomb when she found out how much weight I'd lost, and the short amount of time in which I had lost it. My arms are furry. My BP is low. My hands and feet and (oddly) left butt cheek will randomly start tingling.

But...but...I stammer...my labs and EKG were normal! I'm not wearing children's clothes! My weight has been lower!

The grim reality is this, though: I can't turn it around on my own. I can't just un-flip that anorexic switch and start eating and gain the amount of weight that I need to. Perhaps on some level I get this, although I don't want it to be true.

In a recent blog post, therapist Erika Krull writes what she tells her clients in situations like this:

“You can think that way about your problem if you like, pretend it isn’t there. Or you can face the truth and acknowledge its existence. Either way, the reality of your problem will still be there. You just have more power to make your situation better if you face it.”

Krull writes:

Usually, facing the truth of a difficult situation is a shorter-term pain than most people anticipate. It can hurt like a sucker punch, but then the best part comes. You get the chance to move forward with your life, leaving behind a clunky dirty piece of baggage that you’ve been dragging around behind you. As long as you keep trying to dress up that piece of baggage and keep it with you, it’s going to keep weighing you down. Call it out for what it is, dump it, and get on to the best part of life. Living with honesty.

This is what I am trying to remember, even as I look in the mirror and cannot for the life of me figure out why people are so worked up, can't figure out why I need to gain when I already feel so fat and gross.

I'm sitting here at work, just crying. Tears of utter gratitude and love. I can't believe the support I'm getting right now. It's just...amazing.

If nothing else, this is what is so different about every other time I've struggled and fallen. Before, I kept it to myself. I lied. I concealed. I avoided everyone and everything who might figure it out. I was supposed to be Carrie the Recovery Girl. How could a two-time ED book author relapse?

Um, the same way as anyone else.

Though there is still embarrassment and shame, it is SO MUCH LESS now that everything is out in the open, and now that I realized the only one who ever thought I could never relapse or struggle EVER was, you know, me. I was putting my internal BS on all of you, and it is unbelievably gratifying to know that this was a figment of my imagination.

Relapse is a grim reality for eating disorders. Not inevitable, and not something I think should make you quiver with fear at all hours, but it's always possible. This is the nature of the illness. I've wasted enough time feeling sorry for myself and heaping on all the spoonfuls of self-hatred that I'm really going to try and stop at this point.

Thank you. It feels so trite and cliche, but seriously, thank you ALL.

There's no easy way to write this, no way to make it less awkward and embarrassing (and yes, even shameful) for me, so I'm going to plunge on ahead and get it over with.

I've relapsed.
Big time.

My parents are coming on Friday to move me back to that mitten state in the Midwest, though I probably won't leave DC until Monday.

This relapse struck hard and fast and caught me completely off guard. Things really just started deteriorating in the past 6 weeks--just when I got the boot off and didn't have my handy (or footy) excuse for eating properly and staying off my feet--and by the time I realized the waters of anorexia were reaching up to grab me, it was too late. I was already soaked.

Events would have eventually come to light. The weight loss is blatantly obvious- to others, of course, not to me. I see the same scrubby redhead that I usually see. But during my therapy session last night, I got overwhelmed with guilt and grief and confusing and 'fessed up. I am profoundly grateful I have the best therapist in the world (no exaggeration), that my parents are willing to feed me again, after I ruined things, again. I am grateful I have so many people cheering for me, like Laura and others who read my blog.

But right now, I'm only feeling this gratitude in my head. My heart is full of shame and anger and resentment at Life, The Universe, and Everything and also, you know, me. I do understand that my eating disorder isn't my fault, but I also feel I should have known better. I was not so arrogant as to think that I could never relapse, that this couldn't happen to me. I knew. I knew, perhaps, too well. In the end, though, that's neither here nor there. I can't go back in time. I can't wave a magic wand and make this relapse go away as if it had never happened. Nor should I. I'm pretty much the opposite of a fatalist- I don't usually believe that "things happen for a reason." But I am an advocate of learning as much as you can from your life experiences.

I'm not going to waste energy that I don't have right now trying to understand what went wrong. I get the basics for now, and that's enough. I got really depressed and I let my defenses down. I became too depressed and too defeated-feeling to push myself to eat what I needed to, and so the passive restricting started. I wasn't seeking to lose weight. I wasn't trying to fuck myself and my life over one more time for old times' sake. Something threw my brain into anorexic mode, full steam ahead, and that was the end of that.

So I'm going home, back to the magic plate and refeeding and all of the crap I thought I had washed my hands of. I will wash my hands of them again. It will take time, lots of time, and patience and food and love. I have to believe that, however improbable it may seem to my malnourished brain at the moment.

But my blog isn't going anywhere. It's been my sanity lifeline.

This presentation by Walter Kaye was filmed in March of 2001, before I was even diagnosed with my eating disorder, yet no one ever told me about it or mentioned it. It explains EDs so clearly and succinctly, without blame or psychobabble, that I am astounded no one bothered to let me know this great information.

The New Biology of Anorexia and Bulimia Nervosa: Does Dieting Help People with Eating Disorders Fit Into Their Genes?

You'll need QuickTime to view- I didn't have much luck, so let me know if you can see it.

Otherwise, just click here to view the slides. There's one gratuitous skinny person picture, but it's not too bad.

Then again, I don't know why I'm surprised no one told me about so much of the great information out there. I did find it, yes, which makes me lucky enough to be tech savvy to know how to search and inquisitive enough to go looking. But I shouldn't be the person doing the research to learn all about my own illness. I wish someone out there had told me such great information, right from the get go.

Am I bitter? Maybe.
Has it fueled my passion? You better believe it.

On the subway this morning, I was flipping through one of the free newspapers that they give out when I saw one of the greatest ads, for ironically enough, Gold's Gym.

I liked it so much that I brought it home and hung it on my wall. I tried to take a picture to share with you, but it was yellow text on a dark gray background, so it didn't come out very well. But since it was just text, I figure this should be all the same.

When I wrote about the zone a few days ago, I realized that one of my big triggers isn't so much wanting to get skinny but it's that I'm missing being in the zone. I'm missing that obsessive, single-minded pursuit of...something. That preternatural focus. The endorphins. The zone.

Yet some of the moments when I've felt most alive--or at least most relaxed and "myself"--where when I was in sort of an alternative zone. When I'm making jewelry, say, or snuggling with Aria. When I'm writing or was doing some of my thesis research (reading the articles and connecting the dots into a continuous storyline). No, the feelings weren't identical, but it's been the closest I've gotten in a healthy way.

Just handing me a crochet hook and yarn wouldn't have gotten me into recovery. (If only it were that easy!) ED recovery is a lot more complicated than that. But I find myself more relaxed and less anxious when I'm in the other zone than when I'm just functioning normally. Perhaps this is why knitting has been found to help with ED treatment- besides just lowering anxiety, it also provides a nice substitute for the zone that people in treatment are missing.

Many of the people I've known have found creative endeavors to be helpful in their recovery, and I've always wondered why that is. Some of it is likely getting back in touch with a part of yourself that had been snuffed out by the ED. Some of it might be the playful feelings that creativity can raise. But now I'm wondering whether some of it might be related to being in the zone. That creativity can be a kind of replacement for the ED.

The best thing I've found about the alternative zone is that I am much more in control of when I enter and exit. Though I need some creative stimulation in some form, lest I go more bonkers than I already am, I know I am in charge of when I enter and leave the zone. Of course, there are days when them juices just don't flow and all the words that come pouring off of my keyboard lack grammar and punctuation (kind of like Faulkner, but without the literary merit) and so on, but I can give up or keep going.

That, to me, is the big difference. I did not have control over my eating disorder. I felt the pull of the zone so strongly that I just went there. My brain depended on it. And now, my brain still misses it. But I don't think my creativity is ultimately destructive, colored pencils and silver wire excepted, and it doesn't interfere with my life. It enhances it.