I was out to coffee with two of my friends from DC this morning (L was visiting me, C--my very first friend EVER--was home for the weekend, so all us DC peeps were together in the Midwest) and we got to discussing health care reform. Part of it was shop talk of people who live in DC, and part of it was related to C's job at a non-profit advocacy group that works on health care reform. Although I didn't talk specifically about how this would relate to eating disorders--both L and C know about my history and current relapse--I did think about it.

A little while ago, I read a new paper from the International Journal of Eating Disorders titled "Service users' views of eating disorder services: An international comparison" that really seemed to drive home many of the conundrums I think about with respect to both health care reform and eating disorders. In this debate, the UK's National Health Service is either held up as a good example or how Satan would provide health care, depending on your political persuasion. It is, of course, more nuanced than that, especially in terms of treating eating disorders.

The study concluded the following:

Both samples identified the following as essential aspects of care: good therapeutic relationship, holistic approach, individual psychotherapy/counseling, specialized treatment, client-centered care, and support. In the US sample, the main concerns involved lack of financial accessibility to services and problems with insurance coverage. In the UK sample, lack of and inequity of availability of services were highlighted and three main barriers to accessing care were identified.US and UK service users' views suggest that neither country provides early intervention and comprehensive care for EDs at present, although due to dissimilar health care systems the barriers to care differ.

My own personal opinion is that neither system does a good job of treating eating disorders. The labyrinthine system of insurance coverage and treatment options (most of which aren't covered by insurance) in the US is almost impossible to navigate and just as impossible to pay for. If you have an eating disorder, you rapidly learn the meaning of terms "not medically necessary" and "out-of-network" and how to meet your annual deductible by the third week of January. Options, yes, if you can pay for them, but precious few are evidence-based. In the UK, you face year-long wait lists and draconian criteria for hospitalization. Yes, everyone gets care, if you can survive long enough to get seen.

Both systems have their advantages and disadvantages, but the plain fact of the matter is that we, as a human race, suck at treating eating disorders in particular and mental health issues in general. I don't know of any shining examples out there. No one has all the answers. But I know that some of the answer lies in developing evidence-based treatments and insisting upon their use. Because giving treatment to everyone won't do much good if most of those treatments have no proven efficacy.

Two new research studies out this week have delved more into the issue surrounding eating disorders in midlife (I've written on the subject before here).

One study looked at factors associated with disordered eating and body image dissatisfaction in middle aged women. It wasn't exceptionally mind-blowing research, but it did seem to uphold that many of the traits that put people at risk for EDs earlier in life still put people at higher risk later in life. What traits? Things like placing a high importance on appearance and function, poor self care, and lower cognitive reappraisal. These women also had higher BMIs than women without eating disorders.

The cognitive reappraisal in particular interested me, because this particular study looked at how these women were able to reframe changes in appearance due to aging. So rather than looking in the mirror at their gray hair and crow's feet and thinking "I'm an old hag," a woman could look at the same features and think of them of signs of a life well-lived. It strikes me that these difficulties echo difficulties with set-shifting that have been previously documented in people with eating disorders.

The other study looks at the 20-year outcome of both bulimia and EDNOS, beginning at an average age of 20 years, and ending at an average age of 40 years. Approximately three out of every four people who had BN at the beginning of the study had reached remission by the end of the study. Meaning, of course, that 25% of people with BN fail to significantly improve (though "remission" was not formally defined in the abstract). The authors said this:

Eating disorder point prevalence declined in women but not men from late adolescence to mid-life.Despite patterns of improvement in women, 4.5% reported a clinically significant eating disorder at mid-life, suggesting the need for more research on potential risk factors in this age group, such as pressures for women to maintain a youthful appearance.

And, I might add, research needs to focus on developing better treatments for BN and determining ways to help people stick with treatment.

It would be interesting to see how these numbers compared to rates of midlife EDs twenty years ago. Unfortunately, we don't really have this information. It seems that our culture's emphasis on beauty and youthfulness (or beauty as youthfulness) only helps perpetuate the factors that make people--especially women--vulnerable to EDs in the first place.

Orthorexia nervosa, or an obsession with "healthy" or "pure" eating, is generally considered a type of eating disorder, even though no formal definition exists. Clinicians have been saying that this unhealthy obsession with healthy food has been increasing the past few years, and I wouldn't be surprised if that was the case. Becoming more aware of what we eat (which is good) has also fueled the worries of those who aren't sure what to eat. Everyday, it seems, some new research adds another item to the litany of things we should and shouldn't eat.

How could you not be anxious?

Steven Bratman originally coined the term "orthorexia" in the 1990s, after himself suffering from the condition, and explains it as follows (excerpted from a Smithsonian Blog on the subject):

“Orthorexia begins, innocently enough, as a desire to overcome chronic illness or to improve general health,” he writes. “But because it requires considerable willpower to adopt a diet that differs radically from the food habits of childhood and the surrounding culture, few accomplish the change gracefully. Most must resort to an iron self-discipline bolstered by a hefty dose of superiority over those who eat junk food. Over time, what to eat, how much, and the consequences of dietary indiscretion come to occupy a greater and greater proportion of the orthorexic’s day.”

I started to twitch just a bit when Bratman says "willpower." Because it's not willpower. It's fear. And fear is a remarkably strong motivator. Sufferers of orthorexia aren't avoiding foods because they're "better" or "stronger" than those Oreo-loving, Cheez-Whiz guzzling "normal" folks. It might seem that way--when I was restricting, I often used words like "strength" or "willpower" as so-called motivation. Yet these words cloaked what was really going on: I was afraid to eat. It's a pretty bizarre concept, when you get right down to it, and my brain understood it much better when I thought I was super-strong because I could exist on a diet of lettuce and air.

A sub-headline on a MomLogic blog post about orthorexia explained it much better: Obsessive-Compulsive Driven Disorder. Although I've never been obsessed with food in a strictly orthorexic way, I do have OCD and anorexia, and I know quite a bit about food obsessions. I wouldn't call anorexia the same as OCD, but there does seem to be a significant amount of overlap, both in personality traits and the percentage of anorexics who also have OCD. And orthorexia also seems similar to OCD, with the obsessions focusing on quality of food rather than calories and fat grams.

But Bratman says there is one main difference between anorexia and orthorexia:

"Someone with anorexia does not see her/himself as emaciated, but as fat. Where someone with orthorexia is aware of their extreme thinness but is fine with this, as long as they feel pure."

Except there are well-known cases of non-fat-phobic anorexia, especially in younger children and non-Western countries. So I'm not sure this difference holds up. Another similarity is the fact that both disorders seem to be largely egosyntonic- their illness is giving them the "desired" outcome.

In the end, both disorders can be deadly and debilitating. We need to learn more about orthorexia so that we can start to define it and devise treatments for it.

Would I love an answer to that question or what. After a decade of anorexia, I can tell you that I really have no clue what "normal eating" is. And the other fact is that, after taking a good, hard, look around me, most other people don't, either.

A World of Psychology blogger asked this very question: What is normal eating? The answer, it seems, depends on who you ask.

I like the definition from Ellyn Satter used in the blog post:

“Normal eating is going to the table hungry and eating until you are satisfied. It is being able to choose food you like and eat it and truly get enough of it—not just stop eating because you think you should. Normal eating is being able to give some thought to your food selection so you get nutritious food, but not being so wary and restrictive that you miss out on enjoyable food. Normal eating is giving yourself permission to eat sometimes because you are happy, sad or bored, or just because it feels good. Normal eating is mostly three meals a day, or four or five, or it can be choosing to munch along the way. It is leaving some cookies on the plate because you know you can have some again tomorrow, or it is eating more now because they taste so wonderful. Normal eating is overeating at times, feeling stuffed and uncomfortable. And it can be undereating at times and wishing you had more. Normal eating is trusting your body to make up for your mistakes in eating. Normal eating takes up some of your time and attention, but keeps its place as only one important area of your life.

In short, normal eating is flexible. It varies in response to your hunger, your schedule, your proximity to food and your feelings.”

Satter may have told me to build a particle smasher for all of the fact that this definition helps me figure out how to eat normally. It's perfect as a goal to work towards and a philosophy to embody. But how do you get there?

I know my history of an eating disorder means full-on intuitive eating is probably not a good idea for me. I get depressed, I lose my appetite. I start losing weight, it spirals out of control. So meals are necessary, whether I feel like eating them or not. I certainly look forward to the day when I'm not thinking of food or weight all the freaking time. I don't know how soon it will come, or how long it will stay, but I really do want to think about something besides food. There aren't that many recipes out there.

Nor do I think there will ever be one definition of normal eating. We each have to define that on our own, from a non-eating disordered perspective. What is normal for me--either the types of food, the amount of food, the times and places in which it is eaten--may not be normal for others. That's okay. I think "normal eating" is mostly about learning to trust yourself and your body to tell you what it needs and when.

How have you started to define normal eating? Is there an aspect you're particularly working towards? An aspect you've come to master?

Anxiety continues to be my constant companion, and I twitch and jitter to try and work the nervousness out of my system. I didn't have a specific source for the anxiety, though I seldom do. All I know is that this anxiety is really making me want to exercise. Like run-til-my-shoes-wear-out exercise. It makes me feel better. I took a brief walk yesterday, which helped, but it didn't quite seem like enough to neutralize the anxiety. I still tap-tap-tapped my knee as frenetically as ever, and I could hardly stand to sit still (as evidenced by my lack of posting yesterday. I can tweet on my phone, but I'm not yet talented enough to blog).

This complicated relationship I have with exercise--well, when you get right down to it, it's not that complicated: I'm addicted--was explained a lot by some new research in the Journal of Anxiety Disorders:

Acute changes in obsessions and compulsions following moderate-intensity aerobic exercise among patients with obsessive-compulsive disorder

The researchers found that

Participants reported reductions in negative mood, anxiety, and OCD symptoms at the end of each exercise session relative to the beginning. Changes in the magnitude of the effect of exercise in reducing negative mood and anxiety remained fairly stable while levels of self-reported obsessions and compulsions decreased over the duration of the intervention. Results of this study point toward the promising effect of exercise for acute symptom reduction in patients with OCD.

Well, it's a good treatment if you don't take it too far.

Research like this makes me feel a little less guilty for falling into the seemingly obvious potholes that were in my way. A lot of anxiety resulted in a lot of exercise. In the beginning of this pattern, if I can even find a beginning, I could have made better choices and extricated myself from the cycle. But the anxiety and restlessness of being on exercise restriction (of which I am partially off, yay me) has also driven home how entrenched in the cycle I was.

If I were allowed free reign over my exercise today, would I go back? I don't know. Part of me knows it's bad and stupid and really pointless, but part of me doesn't know if I'd be able to resist a no-holds-barred access to fitness equipment. Which is why I'm staying away from machines and looking into yoga and dance classes.

In the meantime, I just need to find something that works as well as exercise.

A recent op-ed piece in the UK's Guardian suggested that counselling and psychotherapy should be state-regulated. The argument presented in the article asserted that one of the major needs for external regulation was to prevent misconduct and abuse. These are both legitimate concerns and need to be addressed, but my thoughts on more stringently regulating therapy* are related to using the most effective methods possible.

Finding a good therapist is a total shot in the dark. The leading ED "expert" in my metro area when I was first diagnosed was old-school psychotherapy. Yes, there was a couch, and yes, there was the "tell me about your mother." Not that I don't have issues with my mom (my current therapist can tell you that our relationship is very good though definitely not perfect), but discussing them didn't help my ED recovery.

Even in my last ride on the therapist merry-go-round, after I moved to DC, was frustrating. Although she said she used CBT, we didn't really address anything related to eating, which was why I had gone to see her in the first place. The clincher was when she asked, "So did you always feel a need for control or did it start later?" I realize I could have educated her, true, but I was also sick and tired of educating my medical providers. If I knew as much as them, how were they going to help? I don't resent being honest about what I need to work on, but I do resent having to educate "experts" about ED basics (it's a brain disease, it's not "about control," here are some good evidence-based treatments).

Therapy can be a powerful tool that changes the brain, just as do SSRIs and other psychotropic medications. Though I remain skeptical of the FDA's ability to weed out every last one of the bad eggs, the regulation is there. To be certified as a therapist in the US, you need to work under a licenced psychologist for a certain number of hours after graduating from your degree program. You also need to pass the board certification exams. All of which is well and good, but there is still no guarantee that a therapist will be up on the latest tools and research, the latest tests and diagnoses, the newest evidence-based treatments. With MDs, the expectation is much more omnipresent.

Medicine contains aspects of art along with science- I don't deny that. But working with people's brains and lives is a tremendous privilege that should be accompanied by certain responsibilities. I don't want to just feel better after therapy, I want to be better. After so many of my early therapy sessions, I "felt better" because I managed to avoid the hospital and avoid changing my behaviors. I could vent about my horrible, controlling parents, and I could discuss other things as well. But sometimes now when I leave therapy, I don't always "feel better" because I know I'll need to eat more food or start being accountable to myself or any number of things that just plain suck.** The difference is that I'm getting better, which makes me feel better.

Maybe this is less about regulating the actual therapists and more about regulating the types of therapies provided. I'm not looking to create a horde of Mr. Robato therapists- professional judgement is a powerful thing. But just because riding ponies is fun and enjoyable doesn't necessarily mean its effective (no, "research" from Remuda Ranch on equine therapy saying it's effective doesn't count). Nor does reliving your childhood trying to find out what first grade playground event "caused" your eating disorder. Discerning where I got some of my less-than-helpful ideas is useful, true, but the work doesn't stop there. Insight ain't action. I want someone to tell me what approach they're going to use, the reasons that it works, the evidence supporting it, and how the think it will help me.

I would love to hear everyone's thoughts on this, especially therapists (sending flares in your direction, Dr. Ravin!). What are the advantages to better regulation of psychotherapy and mental health providers? What are the disadvantages?

*The article focused on the UK's system, about which I know very little. Nonetheless, I do realize that in the US, anyone can call themselves a "therapist," though there are certifications and boards and internships, etc, to be formally licensed.

**For the record, I do feel better much of the time because I feel I have actual tools to begin combating ED.

"The world has no room for cowards. We must all be ready somehow to toil, to suffer, to die. And yours is not the less noble because no drum beats before you when you go out into your daily battlefields, and no crowds shout about your coming when you return from your daily victory or defeat." --Robert Louis Stevenson

This is something I struggle with immensely: giving myself credit for what I do.

When I first started my job last fall--my first "real" job after grad school and the Big Fat Loser debacle--I had to wake up, every morning, get dressed, and get out the door on time. I've never been a morning person, but that wasn't exactly it. During my last job, I was walloped by depression so intensely that some days, getting out of bed didn't seem to be an option. I put my time in, yes, but at odd hours and in a less-than-functional way. But at this job, it was different. I had my occasional days of turning off the alarm in my sleep, but mostly I got up, I got dressed, got out the door and got to work on time.

So, like, yay me, right?

I scoffed at the idea of congratulating myself for this. I mean, I was valedictorian in high school and salutatorian in college. Clearly, ambition and drive were not things I struggled with, nor was depression a new thing for me. My high school and college years were a torrent of anxiety and depression, but a torrent that left me quite functional. Schoolwork served a similar function to the AN, which it allowed me to channel my energies into a number, and raising (or lowering) that number was a tangible bit of evidence that I could still do something, anything, just one thing, right. If I could go to class when all of this was going on, then why should I feel thrilled for being able to do what everyone else seems to be able to do effortlessly?

Well, I don't know the answer to that. I still don't. I am immensely uncomfortable with praise, seeing that the results were as much from luck or chance as anything that had to do with me. And praise for getting out of bed everyday? Well, halle-freaking-lujah! Even when I did feel momentarily proud that I was functioning like a normal human being, I never felt I could really share it with people. I certainly wasn't going to go tell my co-worker* that I managed to get up on time for five whole days in a row. They probably wouldn't get it, and then they would think I was completely whacked.

What helped was not only giving myself credit for getting up on time, but of letting go of my need for other people to give me credit. You see, I desperately wanted someone else to realize how big of a deal this was for me, but the words stuck in my throat. I was too terrified they would say, "So?" I wanted them not only to understand what a big deal this was for me, but also to understand how much effort it took just to do the simple things they probably didn't think about. Grocery shopping sans Xanax-popping meltdowns. Eating. Getting out of bed.

I've been working on letting go of my need for other people to really get it. I'm sure plenty of people do, but plenty of people don't. I don't need other people to appreciate the victories in really simple things for them to be victories. Would it be more fun that way? Probably. But I was there and am here now and there's this: I get it. I know the effort, the energy, the blood, sweat, tears, and spilled coffee. All of it.

I know the effort behind eating a tiny slice of bread from the bread basket a dinner time when my mom encouraged me, but didn't "make" me have some. A football stadium cheer might be nice for some of these events, but I'm also realizing that not having any notice at all is just as good. Because it shows that I'm returning to normal, that I'm slowly melding back in with the ebb and flow of life where alarm clocks ring and bread baskets arrive and no one really gives a damn.

(quote via Sharon)

*Which I wouldn't have for privacy reasons, even beyond the I'm-not-sure-you'll-get-what-I'm-talking-about part. I don't have co-workers as Facebook friends, and probably never will.

I don't have much to say about this study, as the results kind of speak for themselves:

Common body mass index-associated variants confer risk of extreme obesity

"Our results suggest that [genetic] variants influencing BMI also contribute to severe obesity, a condition at the extreme of the phenotypic spectrum rather than a distinct condition."

So basically, genes have a lot to say about what you weigh. Not that environment has no effect whatsoever; that's not how genes work. But high weight may not be pathological at all. It may just be like being really fair (like me, who wears makeup in the shade of "ghost") or really dark-skinned. There are risks associated with each (skin cancer and rickets, respectively), but the skin color itself is relatively inconsequential.

Same with weight. It exists along a normal distribution, which means that although most people cluster around the average weight, there are people in either extreme. That's just the way the statistics work. Does our current environment of abundant food mean that the "average" weight hasn't shifted a bit? Not necessarily. It might have. But the distribution is the distribution, no matter where you pick "average" to be.

Weight ≠ pathology, obesity ≠ disease.

(h/t Gene Expression)

My therapy sessions this week were unusually productive, yielding several important insights. I spoke with my dietitian at length to start integrating "enjoyable activity" into my life, and I got the go-ahead to begin yoga and walking, so that's good. Along with that came the dreaded meal plan increase, which irritated me (more food? Seriously?) but not as much as it might have.

The food-related insight has several different parts. My food was increased not only in preparation for my increased activity, but also because I wasn't sleeping well. Before my appointment, I was attributing my rise in insomnia with caffeine carelessness or anxiety or whatever. I never thought I might not be sleeping well because I was, you know, hungry or something. Case in point: last night I was up late reading and then I couldn't fall asleep. I didn't really feel hungry, just that my brain wouldn't shut off. I went downstairs and had some mommy time, and then she suggested I get something to eat. Despite my protests that I was fine (and I seriously thought I was), my mom cut me a slice of zucchini bread. And as soon as I started nibbling at it, I realized: Oh. I was hungry. After, I didn't fall asleep right away, but I eventually drifted off.

So the one insight is that even non-perceived hunger can keep me awake. It's a sign that my body really does know what it needs. The other insight is that I'm trying to look at the food increase not as just more to eat, but as a tool to help me sleep better. I'm still not thrilled about it, but I guess that's okay. I don't need to like it in order to eat more.

The other insight came during my therapy session, as my therapist and I discussed my ongoing body image woes. I can't not see myself as anything more than a jiggling ball of lard. And all I can think about when I'm in public is that people are staring at and disgusted by) my quivering thighs. I mean, aren't they giving off aftershocks that can be measured on the Richter scale? And I also brought up how I still have no clue (subjective or objective) what I really look like, especially when it seems I'm constantly watching the National Skinny Person's Convention while I'm waiting to be crowned Miss Blubber. I understand, on some level, that the evidence for this is pretty negligible. I know that the size of my shorts and jeans (Size X) is well below the population average and only contains one digit. Ergo, I'm far from fat. But looking at myself or looking in a mirror, and Elvis and rationality have just left the building.

So my therapist turned the question around a bit. "What would you say if I told you to guess the approximate size of someone who is five foot five and wears a Size X?" Well, I'm five foot five, and my shorts were Size X that day. Yet when I heard it coming from someone else, someone who I know isn't going to bother me with BS, I was able to realize this: "I'd say that person was pretty thin."

And my therapist, bless her red-headed, caffeine-loving heart, said: That person is you.

Although I still have several pounds to go in terms of weight restoration, I am currently about the same size I was before I relapsed. The Size X shorts are still kind of loose, but not freakishly so. So that is me, at my normal healthy weight, and that's just fine. Anyone else would call me on the thin side of average. I've told myself before, "I wear a Size X and people who wear Size X are not fat," and it never seemed o hold much weight (uh, har har) in my brain. But evaluating myself the same way I would evaluate other people, I can better understand that I really don't see myself accurately.

The point of this insight is not Holy Revelation, Batman: Carrie is Thin! It's not so much that I'm seeing myself as thin that makes me feel better. It's that I have a concrete clue to hold onto that just may help me perceive my body accurately. Not that it always works (it doesn't), but it's a way to remind myself that objects in the mirror are smaller than they appear.

I found this Mind Hacks post (Seized by voodoo spirits) interesting on several levels. As someone who has epilepsy--though, fingers crossed, my seizures will remain in the past tense--I relate very much to the search for a "cause." Were my seizures because of the eating disorder? Because of medication? Something else? My seizures began suddenly and with absolutely no warning, coming and going seemingly at random.* Both my family and I were spooked and frightened.

So I read the report of the Haitian woman attributing her epilepsy to spirit possession with no small amount of compassion. And yet I scoffed a bit. As a lifelong skeptic (a cynic when I'm in a bad mood), I find the idea of spirit possession almost laughable. It's kind of like seeing the Virgin Mary in your toast- I mean, the trinity isn't the Father, the Son, and the Holy Toast, amen.

The exact logic and reasoning behind this woman's attributions aren't exactly the point of this post. What got me thinking was the last few lines written by Vaughan:

The cases are interesting as they highlight how easily the 'possession' theory fits with the unpredictable course of epilepsy and its effects when it seems to briefly 'take over' the body and mind of the affected person.

It raises the question of how much observations of epilepsy, a condition that affects approximately 1% of the population, have contributed to the idea of possession throughout the world.

Ideas of epilepsy-as-demon-possession were common in Europe in the Middle Ages and persisted into the nineteenth century. And it made some amount of sense. Human beings like to know "why." We just do. If we can't find an actual reason why rain falls and the sun rises and little Jimmy occasionally falls to the ground and starts twitching, we'll grab ahold of whatever's handy to try and explain it.

This kind of explanation is also common in eating disorders (you didn't really think I wouldn't mention EDs, did you?). When I read stories like this, that are subtitled "Anorexia teenager nearly died to look like Posh Spice Victoria Beckham," I realize how much culture makes a difference in how we interpret an illness.

I don't think this girl is "wrong," per se, because I'm not her and I don't know everything that motivated her. Demons could cause epilepsy- I can't say for sure that they don't, but I can say that there isn't any evidence of this. The same for an anorexic wanting to look like Posh Spice. It's her experience. It's valid. And it does make some amount of sense.

Just as the Haitian woman's beliefs affected her treatment (local medicine man vs. medication), I think our interpretations of eating disorders affect how they are treated. How much control over his/her own behaviors does the sufferer have? What should be the priority- stopping symptoms or more traditional psychotherapy? What causes eating disorders? What is the effect of culture? What about biology?

These are good questions to be answered. Although I have precious few answers, I do know this: EDs are far more complex than a Spice Girl Complex.

*Well, it didn't seem very random at the time as they came and went at about five month intervals, just short of the six month clean slate I needed to get my driver's licence back. Sigh. It does help explain my near-pristine driving record, however.

This is a sad story, all-around:

Mom says Pittsburgh pupil bulled into anorexia

Clearly, someone needed to take the school district to task over this. Administrators and teachers routinely overlook bullying- I know this very well. Some officials deliberately turn a blind eye, while others simply have no clue. Bullying is hurtful and harmful, regardless of whether it results in an eating disorder or not.

However...the bullying didn't cause this poor girl's anorexia. It might have triggered it, yes, in the sense that the bullying caused her to throw her lunch away, which led to the energy imbalance, which led to anorexia. But it didn't cause her anorexia. Science shows us that genetics form the biggest risk factor for eating disorders, although many environmental factors can play a role in triggering the disorder. This type of bullying is sadly common, and if every case resulted in anorexia, we would have many more cases of eating disorders than we presently do.

Will this girl benefit from some good therapy to help her deal with the bullying? Absolutely! It caused real distress, even outside the eating disorder. What we don't know is whether she might have developed AN if she hadn't been bullied, or if administration officials had stepped in. Maybe she would have, maybe she wouldn't. We just don't know.

Schools should refuse to tolerate bullying because it's harmful and wrong, not just because someone developed an eating disorder. I'm not naive enough to think that bullying will ever stop, but we can stop accepting it as a normal phase of growing up. And that's a good thing even if it has no effect on the number of cases of eating disorders.

New research points to the potent addictive effects of excessive exercise. When exercise-addicted rats were given naloxone, a chemical used to block the effect of opiates, they experienced withdrawl effects, such as "trembling, writhing, teeth chattering, and drooping eyelids," whereas inactive mice did not.

From a press release:

The active rats who had access to food for only one hour a day both ran the most and displayed the most severe withdrawal symptoms. Like people with anorexia athletica, they ran so much that they lost significant amounts of weight. Additionally, the more a given rat had run, the worse its withdrawal symptoms after naloxone. In contrast, regardless of how much they ate, inactive rats responded very little to the drug.

Because of the way the active rats responded to naloxone, they seemed to have undergone the same changes in the brain's reward system as rats addicted to drugs. "Exercise, like drugs of abuse, leads to the release of neurotransmitters such as endorphins and dopamine, which are involved with a sense of reward," noted [lead researcher Robin] Kanarek.

Insights into behaviors that trigger the release of the brain's "reward" chemicals may lead to addiction treatments that incorporate moderate exercise, according to the researchers. The findings also suggest that active rats given limited food may make a good experimental model for studying and developing treatments for anorexia athletica, added Kanarek.

The paper itself (free and full-text!), "Running and Addiction: Precipitated Withdrawal in a Rat Model of Activity-Based Anorexia," had some very interesting findings. There, the authors directly linked the commonalities between drug and exercise dependence. They found that "excessive running shares similarities with drug-taking behavior."

Similarities between the effects of exercise and drugs of abuse extend beyond opiate drugs. Research demonstrating that rats will perform operant responses to obtain access to either drugs of abuse or a running wheel provides evidence of the rewarding properties of both drugs of abuse and running. Moreover, under certain circumstances, such as food deprivation, both drug selfadministration and running escalate and become maladaptive behaviors. These findings suggest that running may be able to substitute for drug-taking behavior. In support of this suggestion, rats running in activity wheels self-administered smaller quantities of opiates, alcohol, and psychomotor stimulants (e.g., amphetamine and cocaine) than rats housed in standard cages.

{snip}

The finding that symptoms resembling those of opioid withdrawal occur in food-restricted active rats may have correlates in clinical populations. Excessive exercise is a common symptom of eating disorders, particularly anorexia nervosa Initially, physical activity is used as a means of weight control, but with time it can become an end in itself. In the extreme, individuals with eating disorders can have difficulty refraining from exercise despite adverse physical consequences (e.g., an unhealthy decrease in body weight; decreased bone density; stress fractures). Additionally, symptoms reminiscent of drug withdrawal, including anxiety, depression, and irritability, often develop when these individuals are unable to exercise. The high comorbidity of drug abuse and eating disorders provides further evidence of a common neurobiological basis for these disorders.

The authors also found that female rats showed much higher rates of excessive running than male rats under similar conditions. Furthermore, the authors noted that they were unable to determine whether the withdrawl was specifically due to the increased exercise, or whether it was confounded by differences in food intake and body weight in the active rats.

I would also be curious to see if people with exercise addiction have higher or lower rates of opiate abuse. I could see it go both ways: higher levels of abuse because your system is "primed" for the flood of endorphins, or lower levels because you're getting those endorphins via exercise. It would be interesting to look at how other addictive behaviors overlap in EDs, and whether relatives of those with exercise addiction have higher rates of other addictive behaviors. The authors also suggested that moderate exercise might be a good prescription for those addicted to opiates as it is a non-maladaptive way to get that nice endorphin rush, though I would be hesitant given the known neurochemical overlap between these two addictions.

To me, exercise was a very safe and egosyntonic addiction. Whereas random strangers would have been alarmed if I started shooting heroin (which, given my OCD-related AIDS fears would seriously never ever happen), but they told me how "good" and "dedicated" I was when they learned about just a few of my exercise habits. If exercising X hours each day makes me "good," I figured, then the actual Y hours that I do must make me "fantastic!" I wasn't going to be arrested for having gym shoes on me, or a collection of rank sports bras in my closet. I am almost pathologically risk-averse, so exercise is probably the ultimate addiction for my personality, and I fell in to the trap head-first.

I love quotes. I like the really oddball ones, or inspirational ones that no one else knows about. I got heaps of inspirational quotes each time when I was in treatment, but most of them made me gag a little bit.

Be a butterfly!
You can do it!
Stick to it like a stamp!

Some of this I think I might have gone for if I hadn't heard them so frequently they became rather cliche. Instead, I've kind of compiled my own list of favorite quotes, and here are a few of my new favorites:

"There is no progress without struggle." --Frederick Douglass

"I will be as strong and as weak as I need to be." --Thomas S. Szasz

"If you're afraid of butter, use cream." --Julia Child

And my all-time favorite that I used at the conclusion of my second book:

"Trials never end, of course. Unhappiness and misfortune are bound to occur as long as people live, but there is a feeling now, that wasn't there before, and isn't just on the surface of things, but penetrates all the way through, that says: we've won this. Things are going to get better now. You can sort of tell these things." --Robert M. Pirsig, Zen and the Art of Motorcycle Maintenance

I remember when the OCD first struck. Sure, there had been plenty of signs of anxiety and obsessionality before then, but on one December day of my ninth grade health class, my OCD came crashing down with a thunk. We were learning about AIDS, and I promptly freaked. Freaked is, perhaps, an understatement. I had an anxiety attack so intense that I ran to the bathroom, threw up (not intentionally, I was just so anxious that I couldn't keep my breakfast down), and washed my hands. Twice.

And that was the beginning of that.

I wasn't especially anxious about AIDS before this incident. I mean, I was a little bit, but nothing even remotely crippling. A little anxiety can be a good thing in terms of disease prevention. It might make you think twice before sharing a needle or having unprotected sex with a stranger. But this was the mid-90s, and the second round of AIDS hysteria was picking up. The second round was more a This-Can-Happen-To-YOU kind of moralizing, and news pieces on TV and in magazines only confirmed what I was already afraid of. It wasn't just a random 15-minute video in health class, these fears were all around, all the time. Every article, it seemed, only confirmed my nagging fears that people were simply germ-spreading machines. I was smart to be worried. I was right. Why weren't others so worried? What was wrong with them?

Granted, most people I knew weren't scrubbing their hands in Ajax and puking from anxiety, but still.

The last line in a Guardian UK piece called "Pure food obsession is latest eating disorder" got me thinking along this line. The article looked at the seeming rise in rates of orthorexia, or an obsession with healthy eating. The last quote of the article, by nutritionist Deanne Jade, was what stuck with me:

"And just look in the bookshops – all the diets that advise eating according to your blood type or metabolic rate. This is all grist for the mill to those looking for proof to confirm or encourage their anxieties around food."

This quote reminded me of the beginnings of my OCD: everywhere I turned, my fears were confirmed. I couldn't convince myself that this was not a smart thing to be worried about--or, at least, so worried about. I was aware that my behaviors were bizarre and my fears overwhelming, but when you see all of this hysteria all around you, it's kind of hard to realize that you have an actual brain disease.

Is this rise in orthorexia a bit more complex than this? Of course it is. There has been an increase in a wide variety of specialty foods that allow people to custom build their diets. For those with real dietary limitations, this is great. But it also has allowed those who have food anxieties to avoid anything anxiety-provoking. And as someone with plenty of food anxieties, I can attest that any magazine will confirm my fears of becoming fat or of eating too much or of not eating the "right" foods in the "right" quantities at the "right" times.

A little anxiety over food isn't necessarily bad. Roaches don't add flavor, and neither does Salmonella. But considering how much we are all fanning the flames, it's little wonder that the severe, clinical fears are only rising.

We know a lot more about eating disorders than we did ten or twenty years ago. But with that knowledge comes the rather sobering fact that we still don't know a whole lot. At Lobby Day 2008, Dr. Cindy Bulik said that we lacked even basic epidemiology on the prevalence of EDs in the general population. People have extrapolated and guessed, but that's kind of like saying you live in the US somewhere west of NYC and east of LA. It doesn't exclude a whole lot.

Besides the epidemiological data that we lack, there is also the problem of how to define and diagnose eating disorders. The gold standard is the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition* which basically describes each "mental disorder" as a syndrome. That is, the DSM doesn't go into detail as to what causes the illness, which is unlike many other medical conditions (i.e., the definition of tuberculosis includes the identification of the causative Mycobacterium tuberculosis), but instead just describes signs and symptoms that can be identified by doctor and/or patient. The Wikipedia entry on "syndrome" says that the word

is most often used to refer to the set of detectable characteristics when the reason that they occur together (the pathophysiology of the syndrome) has not yet been discovered.

In simple parlance, we don't know a whole lot about what causes the disease, but we can identify it. Although we know a lot more about what causes eating disorders, we don't know the exact sequence of events, nor do we know what factors are necessary to result in the development of an eating disorder.

Which is why I think that the recent paper titled "Clarifying criteria for cognitive signs and symptoms for eating disorders in DSM-V" is so important. If we can't find a specific bulls-eye to diagnose an eating disorder, then we can at least make that bulls-eye as small as possible so that people who have eating disorders can receive a proper diagnosis.

The researchers, led by Anne Becker at Harvard, took on some of the most profound and disabling aspects of eating disorders: the underlying cognitions.

The literature supports several reasons that individuals with an eating disorder may not endorse cognitive symptoms, despite their presence. These include limited insight, minimization, or denial, as well as intentional concealment related to perceived stigma, social desirability, or investment in maintaining behavioral symptoms. We also identified reasons that the word "refusal" in AN criterion A may render its application problematic.

In my opinion (and this is getting back to A's excellent comment on yesterday's post), it's the cognitions, not the weight, that ultimately delineates people into having anorexia or not.** Not that the behaviors are irrelevant--far from it. But thoughts and behaviors exist in this enormous feedback loop, and both must be changed for ongoing and lasting recovery.

Even using cognitions to define EDs can be problematic due to the prominence and prevalence of dieting and food phobia in our culture. We need to get better at making these distinctions, since I doubt our obese-o-phobic society is going anywhere.

*This was on my list of recommended books on Amazon the other day, causing great laughter and hilarity on my part.

**I am less familiar with how this might apply to bulimia, and I am also tired so I won't tackle it in this post. But I think the frequency of binge eating and purging is important- one episode is definitely problematic, but how can we say that it's a disorder? Daniel LeGrange's group found an actual clinical difference between adolescents with full-blown BN or sub threshold BN. How significant that is, I don't know.

Virtually all eating disorders begin with a diet. And chronic or pathological dieting can easily progress into an eating disorder. I would never really dispute this, as the research supporting it is quite established and quite solid. A period of inadequate nutrition tends to be the last straw that pushes someone from being "at risk of developing an eating disorder" into "actually having an eating disorder."

This does not mean that an ED is just a really big diet.

Which is why this article has me more than a little tweaked: Too much dieting could be anorexia

Anorexia and strict dieting can look the same from the outside, and can even start off the same: food restriction, eating "healthy," reading food labels, exercising more, becoming obsessed with food and cooking. Some of these are sympoms of malnutrition, some of them are just common links. But that's where the similarities end.

Dieting is a choice.
Anorexia is a brain disease.

Dieting is choosing to eat less.
Anorexia is the inability to eat enough due to a fear of food.

Big difference.

So yes, dieting can look like anorexia, and people with anorexia often claim they are dieting or eating healthy. People with anorexia can often think that they are just dieting or eating healthy. A diet can turn into anorexia. But dieting has an element of voluntary choice that's simply not there with anorexia and other eating disorders. No, it's not that simple to just stop dieting, but there is some amount of control over your food-related behaviors. With eating disorders, that virtually disappears.

Not that remedying this misunderstanding will fix everything that's wrong in the ED world, but this seems as good a place as any to start. Once we stop looking at EDs as a bunch of wacky diets undertaken by vain little girls, and start accepting them as a brain disease that needs urgent, immediate treatment, the better off we'll all be.

The article itself didn't arouse too much ire in me, but the headline sure did! So I'm asking you yet again: journalists, please try harder.

A sudden spate of new research on emotions in anorexia nervosa has definitely caught my interest, as emotions are not something that come easy for me. It's not just a feel your feelings sort of thing, but also a "I know I'm pissed and anxious, so now what" kind of thing. I feel emotions and I feel them hard and deep. I can usually identify them, but regulating them and living with them isn't one of my strong points.

A new study, titled "Emotion avoidance in patients with anorexia nervosa," found a strong relationship between levels of emotional avoidance, anxiety, and ED psychopathology in people with AN.

"Patients with AN endorsed levels of emotion avoidance that were comparable to or higher than other psychiatric populations and exceeded community controls...[These] findings confirm that emotion avoidance is present in patients with AN and provide initial support for the idea that anorexic symptoms function, in part, to help individuals avoid aversive emotional states."

Which makes a lot of sense. Anxiety is quite possibly one of the biggest triggers I have, and not eating makes me feel less anxious. And the strong relationship between anxiety and eating disorders hasn't gone unnoticed. Walt Kaye's group out at UCSD found this to be true experimentally.

Another study, titled "Emotional processing in women with anorexia nervosa and in healthy volunteers," found that

"Compared to the [healthy volunteers], patients with AN had lower levels of self reported emotional awareness and expression. They also responded more slowly to, correctly identified fewer emotions and misclassified more emotions in a facial recognition task, and responded more slowly to, and recalled fewer, self-referent emotion words."

Previous research has suggested that adolescents with anorexia had impaired emotional processing compared to non-anorexic adolescents.

A study from earlier this year, "Emotional perception in eating disorders," found that

"Patients with AN-R showed increased fear when confronted with stimuli containing anger, whereas patients with BN showed a tendency towards decreased fear...The finding of increased fear when exposed to the emotion of anger might be attributed to introversion and conflict avoidance of anorectic patients."

Which I have again found to be true in my personal experiences. Anger, whether mine or anyone else's, tends to terrify me. I typically avoid conflict, but my mom has also described me as "scrappy" at times, so it's not a 100% thing. I'll charge in if no other alternative is open, or if I'm feeling quite peeved, but usually, I just stay in the background. Some of this hanging back is conflict avoidance, and some of it is my innate introversion.

Other, more qualitative, studies have also looked at emotion perception in anorexia nervosa and the use of emotion-focused therapy to treat AN. I don't find either of these two studies as promising as the first three, largely because the results don't seem to be as concrete or reproducible.

Regardless, issues with emotion processing and recognition are neither purely genetic or purely environmental but arise from an interaction between the two.

The wonderful parent-advocacy organization FEAST is now on Facebook!

Check out the FB FEAST page and feel free to join us.

FEAST on Facebook

Here, you can keep up on all of the latest FEAST happenings, ask questions, get answers, and otherwise be nosy, Facebook-style.

Please join us!

I've been thinking a bit these last few days about life in recovery and life after recovery. I've had to work with human resources to sort through some work-related issues pertaining to my disability leave. I know I'm not ready to go back yet- I don't think I'm yet capable of being able to eat everything I need to day in and day out. I also have some more weight to gain, and as my metabolism has begun fighting back big time, progress on that front has slowed dramatically.

All of these issues, together, have prompted me to ask a bunch of rather existential questions of myself, and what I want my life to be like once I put this damn eating disorder behind me.

The long and the short of it is: I'm not exactly sure. I know writing will be at the center of my life, as I enjoy it and have found that others are willing to pay me to do it, so all is well. I have also found my groove in ED advocacy, in spreading the word about the latest treatments and the latest research and helping people make sense of this. I'm not sure whether I want this to be a career or more of an avocation, a hobby and passion outside of whatever kind of day job I end up with.

I have this fundamental need for recovery to make sense, for it to have meaning.

For years, I ascribed meaning to my eating disorder. It was my feminist "up yours" to the diet industry. It was an existential crisis writ in skin and bone. It was a misguided search for control and power. It was a way to separate from my family.

Blah blah blah. I think my eating disorder has meaning within the context of my own life (i.e., it's kind of hard to be sick for a decade and not have it come to mean something, even if it was "I frittered away my 20s with anorexia."), but I don't think an eating disorder necessarily means anything. Which left me grasping at what I wanted to make of recovery. If my eating disorder didn't have an inherent meaning, how could recovery?

But just as I worked so hard to find meaning to my eating disorder, I need to find meaning for my recovery. Not as a way to explain it or even understand it, but as a way to propel myself forward. Some people wake up and hear the chirping birds and just bounce out of bed, ready to take on life. I'm not one of those people. I want a reason to put up with the hell of refeeding and recovery.

Ultimately, I just want recovery to be worth it. I need to believe this, down to my very core, that recovery will have been worth it. As this belief faded, my relapse only picked up steam. Sure, I was physically doing better, but I was still mentally a mess. The benefits of holding on to life and sanity suddenly couldn't equal the costs of maintaining my weight and keeping strong tabs on my exercise. Yes, my relapse was a hell of a lot more complicated than that, but this was at the core.

I realize that a meaningful life isn't a prerequisite for recovery, and that building a meaningful life will be one of my major tasks of recovery.

Sorry to have been out of contact for the last few days, but I was completely without internet. As the wi-fi on my laptop is broken (I haven't gotten it fixed in part because I just never got around to it and in part because I can focus on my writing much better when I don't have Firefox luring me out of the corner of my eye), I wasn't able to move into a Starbucks or similar facility, either.

Alas.

But I am home. My head hurts, I'm tired, I feel queasy, and I can hardly keep my eyes open, let along think straight, but I am home. Back to my sacrosanct habits and routines and things that are safe and familiar. Parts of my trip were fun, parts weren't, and some parts were more on the eye-opening side.

I will be updating the blog more tomorrow. Er, later today. After a good sleep, some ibuprofen, and a couple cups of coffee.

I'm not sure why this realization took so long for me, but it did. And it was all thanks to my good friend L. I have been back in DC, frantically packing up my apartment, and I've gotten together with L. twice- once on Monday, and once tonight (Wednesday). Both times were very enjoyable and we talked and laughed and even gossiped a bit. This was much more fun than spending time with ED.

The differences between ED and my friends are quite profound.

ED makes me feel better, but only short-term. And then it drives everyone else away and I lie and tell stories and stop recognizing myself.
L. makes me feel better both short- and long-term.

My parents hate ED.
My parents like L.

ED takes the sparkle out of my eyes.
L. says how great it is that the sparkle is coming back.

ED has tried to kill me (and nearly succeeded).
L. hasn't.

ED tells me not to eat.
L. gets out snacks when I come to visit.

ED is an abusive bastard.
L. gives great hugs.

ED says I'll feel better if I starve/purge/exercise.
L. just listens and I feel better almost automatically.

The irony is that when my eating disorder started, I started to take a positive spin on my overwhelming loneliness (I was working at an internship in a strange city where I didn't know anyone). If I didn't have any friends, then I wouldn't have to eat with them. I began to think of friends as a waste of time, something to keep me away from my laundry list of rituals and must-dos. Because I would feel so anxious when I couldn't do whatever it was, even the idea of going out with a friend made me nervous and upset.

The ongoing depression and ED symptoms made it hard for me to begin new friendships and nurture previous ones. But I am slowly getting better at this, at letting people in, at loosening my white-knuckled grip on my rituals and activities. I am finally learning how to sit back and just enjoy someone else's company and be there with them in the moment.

I'm not sure why it took me so long to realize that these friendships meant far more to me than the ED, but I'm glad I learned that lesson.

Once again, the Onion nails it. This time, it was the piece titled "Study: Abstinence-Only Lunch Programs Ineffective At Combating Teen Obesity," which managed to poke fun not only at many of the anti-obesity initiatives, but also at abstinence-only sex ed. And it really drove home the point that food is the new chastity belt.

Some highlights from the article:

"There's no evidence to suggest that instructing teens not to chew, swallow, or even think about food is actually going to stop them from eating," Sebelius told reporters. "Let's face it: Kids are already eating. And not only during lunchtime. They're eating after school, at the mall, in their parents' basements. Pretending like it's not happening isn't going to make it go away."

"After all, they're teenagers," Sebelius continued. "Eating is practically the only thing on their minds."

Perhaps more troubling, students who completed the abstinence-only program were reportedly unable to answer the simplest questions about their own digestive systems, and some as old as 17 still believed they could catch high blood pressure from their very first Snickers bar.

"Kids need to know the truth about food," said Sue Weber, a nutritionist. "It's irresponsible for these schools to fill their students with misinformation about the devil working through trans fats, instead of just saying to them, 'Look, I know eating that entire box of Cheez-Its might feel good now, but when you're older, you're going to wish you had gone for the salad.'"

[snip]

"I'm never ever going to eat, because eating is wrong, and I'm worth more than a chicken sandwich with asparagus and rice pilaf," Woodbridge seventh-grader Tracey Holmes said. "I heard Jennifer Hines eats all the time, like 50 times a day. I heard she eats all her ice cream upside-down, though, so she doesn't get fat. That's how it works."

Food and fat have almost replaced sex in our cultural repertoire of Things That Make Women Bad, so the comparison to abstinence-only sex ed is more than spot-on. Thankfully, I'm no longer a teenager (and I have less than one year left in my 20s), so I can't tell you from experience whether this is true or not, but when I was in high school, the big freak-outs were over STDs and teen pregnancy. Certainly things like "healthy eating" were mentioned and discussed, but there were also cupcakes for birthdays and Coke in the vending machines.

Now it seems the obesity epidemic has almost overshadowed all those worries. Maybe in another ten years, we'll find something else to freak out about. In the meantime, read the article and enjoy.

(Image courtesy The Onion)

Via the Academy for Eating Disorders' email listserv, I found out about an upcoming game for PlayStation 3 called "Fat Princess."

From the text of the email:

The purpose of this game is to prevent the princess from being kidnapped by making her too fat to carry. To do so, the characters must navigate through a castle avoiding enemies and obstacles to find cake. They then must bring the cake back to the princess and feed her. When the characters feed her a piece of cake she significantly gains weight (as the announcer in the game preview states, she is no longer her light airy self).

As I am sure is obvious to each of you, the premise of this game sends a myriad of dangerous message to the general public as well as those at risk and suffering from eating disorders and/or body image concerns. It clearly does not promote the notion of size acceptance. Furthermore, advertising for the game has welcomed all sorts of puns such as "Fat Princess Worth the Weight" and "Fat Princess Let Them Eat Cake."

You can watch a brief 30 second trailer of the game below:



It is the longer preview of the game with its accompanying commentary that is the most inappropriate (with the highlights coming at 1:50 or so):



I will be contacting PlayStation directly, and am encouraging you to do so as well.

Sony Computer Entertainment America
Human Resources
919 East Hillsdale Boulevard, 2nd Floor
Foster City, CA 94404

The content of this game is inappropriate, discriminatory, and frankly inaccurate. It sends the wrong message to anyone that a single piece of cake will make you noticeably fatter, and that skipping the cake will turn you back into your "airy self."

I love it when a seemingly little insight can yield so much understanding. In this case, the insight isn't from therapy or thinking, but instead from research (and a cleverly worded press release).

Why Anorexic Patients Cling to Their Eating Disorder

This has been a topic of much conversation and consternation in therapy for me. My one therapist, Dr. G, would always ask me what I was getting out of the eating disorder because "there had to be something since I kept on starving myself." It's true that my eating disorder had an adaptive function, but in those moments when I could recognize how ill I was, I usually wanted to rid myself of the eating disorder, not cling to it. But Dr. G and I discussed things like control and mothers and feelings and some of it was useful and some of it was simply a time suck.

Many times, I didn't really have an explanation for my behaviors. I didn't necessarily understand them myself, and when an understanding did dawn on me it rarely resulted in real, lasting behavioral change. A lot of times, the ED behaviors were just a part of my routine. I woke up, I did X. At "lunchtime", I did Y. After work/school, I did Z. I ate the same breakfast every day for almost two years because choosing a different cereal was overwhelming and I had planned my meals around this one particular type of cereal so I kept on eating it.

The recent paper from the American Journal of Psychiatry titled Neural Correlates of Impaired Cognitive-Behavioral Flexibility in Anorexia Nervosa, found that my experience with a need for routine and inflexibility was common to many AN patients. In fact, the researchers hypothesized that anorexics "clung" to their disorder because they had difficulties in developing new behavioral patterns.

“In this study, we confirmed that anorexic patients cling to familiar behavioral responses more frequently than healthy subjects, thus suppressing alternative behavior," explained Dr. Hans-Christoph Friederich, head of the working group for eating disorders. The analysis of the MRI images also showed that in patients with anorexia compared with healthy subjects, a certain network pathway between the cortex and the diencephalon is less activated. This network pathway plays a decisive role in initiating and controlling actions under rapidly changing environmental demands.

The results of the study contribute decisively to a better understanding of anorexia. In particular, they make it clear that neurobiological factors are involved and sustain the clinical symptoms. Since psychological and neurobiological factors can influence each other, this may lead to new therapy approaches for anorexia.

"We have developed a treatment program for anorexia patients that specifically targets the flexible modification of behavioral responses,“ says Dr. Friederich. In this way, the researchers hope to improve the success of psychotherapeutic treatment. The MRI examination of the brain could contribute to measure the success of treatment.

(I inserted the links in the above quotes)

I've been on exercise restriction for the past two months as I try to get my weight back up where it needs to be, and the reality of it is that this sucks. I really miss exercising. I know I was struggling with an exercise addiction, and that some of this craving is not altogether healthy. But some of what I miss about exercise, I'm coming to learn, has very little to do with exercise itself.

First, let me set the scene of one of my usual workouts. I tied my hair back with a red bandanna. I wore ankle socks and running shoes. I had my keys, my water bottle, and my iPod turned on full blast. I started each workout with the same song. I've destroyed my knees and ankles through excessive exercise, but I've also probably ruined my eardrums, too. When I hop on the machine, I was usually edgy, twitchy, frenetic, tense. And then I started pedaling/stepping/walking/running/elliptical-ing and all of that edginess began to fade into the background. With each step, each push of the pedals, it faded further away. By the end of my workout, those stresses were X hours or X miles away from me.

At the end of my workout, I would let out a deep breath. I could breathe again. I listened to my post-workout song on my walk back to my apartment (I only let myself listen to this song if I completed the entire workout). It was my ritual: song, shower, PJs. OCD much?

While I was exercising, I felt untouchable, invulnerable. Not in the sense that nothing could ever happen to me while I was exercising, because I was voted class klutz in high school. Getting smacked in the face with a kickball in high school gym, such that my braces were jammed into my cheek and had to be yanked out was more than enough to prevent that delusion from ever returning. But untouchable in the sense that nothing could bother me. I didn't have my cell phone, so no one could intrude. The blaring music from my iPod literally blocked everything else out. I was in my own little zone in my own little world.

And that is what I miss- the distance from all of the things that are bugging me, that block of time in my day (or blocks of time, to be really honest) when I wasn't constantly obsessing over everything. I sort of loosened the reins on my brain and just let it wander wherever it felt like. Some of the daydreams were ED-related, but many weren't. Sometimes, I didn't exactly think at all. No one could need my attention because they couldn't get it. I was away from my phone and email and whatever it was could and would wait. All of the stresses, those things I needed to "fix," such as folding the laundry and cleaning Aria's litter box, were somewhere else. However sweaty and stinky and exhausted I was when I was chained to my exercise machines, I wasn't interrupted, I wasn't bothered, and I felt at peace. It was like Calgon had taken me away.

My cousin's wedding this past weekend was stressful, both in ways I've mentioned, and ways I haven't. All I wanted to do last night was go for a long, sweaty run and let the pounding of my feet replace the pounding in my head. And I couldn't. So I let the hot water in the hotel shower pound on my back and slow my racing heart, taking deep, raggedy breath after deep, raggedy breath. I felt better after my shower, but it wasn't the same. I had to take a step off the beaten path.

I know that part of me misses that almost constant movement and my body literally craves a physical outlet for all of my anxiety. And exercise did help me deal with stress in a healthy way at first, and that's what I ultimately want to get back to. In the meantime, I need to find a replacement for all of the non-movement-related things that exercise did for me.

Any suggestions?