This is the last in the "roadblocks to recovery" series- I have gotten tremendous feedback from you all, and I'm just tickled that everyone seemed to get a lot out of it. It almost makes me wish I had more roadblocks so I could keep blogging this series!

Almost.

The ED is familiar

I wrote yesterday that an eating disorder can make life simpler, but even complex things can become relatively simple if you practice long enough. More than simple, however, the anorexia is familiar. I no longer remember what it was like to eat without fear or counting calories. I don't remember what life was like before my exercise routines (they replaced study routines, which I guess just goes to show you how much I like routines). Until my most recent job, I had forgotten what it was like to bring a lunch to work, to pause for a snack, to allow myself to be seen eating. Early in my eating disorder, I remember telling myself that I needed to bring a lunch with me, but I could never remember to take it with me. Even now, it feels odd to take a lunch to work, to be seen with tangible evidence that I actually eat.

It's change. Recovery is something new and something different. And if you crave the familiar and routine like me, then you'll know what I mean when I say that I avoid even good change because it's change! The ED was predictable. I knew what to say and do. I had my day planned out down to the minute. It was comfortable and familiar.

An eating disorder is NOT a habit, but some ED behaviors can become habitual--the flipping of a box to look at the "Nutrition Facts" information, for instance. Or the perpetual hopping on and off of a scale to make sure you got the "right" weight. Or, as I mentioned above, not eating lunch. I went through a period where all I would eat was finger food- nothing that required a utensil. After several weeks of this, I ate dinner at my parents house and I remember picking up a fork and it taking a minute to remember what the hell I was supposed to do with such a thing.

An ED is hell, but it's a familiar hell. It's a hell I know how to cope with. It's a hell that has some amount of rhyme and reason and (dare I say it?) functionality to it. Being hungry doesn't bother me much because I'm used to it. I used to freak out during re-feeding because I wasn't used to feeling full and it completely freaked me out. What is that feeling? What is wrong with me? How can I make it go away?

Recovery is new and shiny and really rather strange. It often takes me a long time to see if I'll like something or not, and I'm not always 100% gung-ho positive about this recovery thing. I know the alternatives suck even more, and so I'm sticking with it. Who would have thought that one day, I would think that not wanting to throw myself under a bus would feel almost wrong? Who would have thought that one day, I would be enough in control of my anxiety that I could sit and watch a movie from start to finish and that this would feel weird? But this is recovery. It's not all of recovery, but it's part of it.

I'm still trying to come to terms with the fact that change isn't necessarily bad, and that I have the mental and emotional capacity to cope with whatever comes my way.

I hope you all enjoyed this series- I'm going to add these posts to my "Pages" list up top for easy reference.

Life is enormously complicated. There are interpersonal relationships (friends, family, co-workers, etc) and there are any number of variables that we flat-out don't have any control over. Although I don't think an ED is "about" control, control is a theme in many eating disorders, and mine was no exception.

I don't get nostalgic for the good ol' days of AN much anymore, but when I do, it's usually because life has gotten complicated and I miss the AN simplicity. Which brings me to my next roadblock to recovery:

An ED Makes Life Simpler

When I am in the midst of my eating disorder, I care about three things and three things only: how much I ate, how much I exercised, and how much I weigh. I might not have any clue how I'm going to tackle the next big project at work, but it's all good- I'm losing weight. I might be getting really nervous about how I'm going to pay all my bills, but it's all good- I'm exercising a lot. Ta-da! It's simple. As long as I can have an iron control over what I (don't) eat, then life becomes tremendously simple because nothing else matters.

Of course, the fact that starvation makes your brain fixate on OMG FOOD only makes the simplicity more pronounced. Because literally, the only thing you can think about is food. Even when I needed to think of something else, I couldn't. My life was all about food and how to avoid it. Granted, the mental and emotional gymnastics I had to perform to make sure I avoided food was far from simple. I tried to anticipate any and every circumstance that might possibly disrupt my planned food or my exercise routine. Nonetheless, these mental gymnastics were far simpler than life in general. I learned to deny, isolate, lie, and hide to maintain my disorder and the seeming simplicity it brought.

When I was acutely ill, I wasn't all that worried about the distant future- I rather assumed the eating disorder would kill me. I also had anorexia as my trump card, so as long as I was alive on surviving on minimal food, then the future didn't matter all that much.

Food. Weight. Calories. Exercise. These things are so simple to manage when compared to the complex world of relationships and getting your oil changed, of paying bills and taking care of loved ones. Life requires all of us to juggle many different roles, many different tasks, and many different personas depending on what is required of us at the moment. When a friend asks me over for dinner, I have to determine whether this conflicts with other responsibilities, whether those responsibilities can be cancelled, whether an aging grandparent might also need my help, and how likely it is I will be asked to work late. When an active eating disorder is in that picture, I just decline the dinner invitation because dinner=food=eating. It's an easy decision. Selfish, perhaps, but definitely simple.

Recovery means accepting the full catastrophe of life. It means juggling many different roles and tasks, and it also means that you won't be everything to everyone. It means dealing with people rather than calorie counting manuals. It means--and this is a big one for me--accepting uncertainty and imperfection.

So I've been at my new job for two weeks now, and I must confess it is much different than most of my previous jobs. For starters, I am busy all the freaking time with no moment to catch my breath, check my phone/Twitter/email, or even visit the restroom much. Almost all of my jobs in the past decade have entailed me, sitting at a computer and reading/typing. At the bakery where I work now (I know! I know!), I'm on my feet for the entire 8 hour shift, running to and fro and doing tasks with a minimum of intellect required. That's not to say that my co-workers are stupid--far from it--just that the work itself doesn't require a huge amount of higher level thinking. It's more like "smile--take bread--put on gloves--slice bread in machine--put sliced bread in bag--hand back to customer--smile." I'm not scrutinizing a scientific study and my pay reflects that fact. That being said, I rather like my job.


My back, however, does not. I have a herniated disc in my mid-back from a cycling accident about 8 years ago. It has ached on and off, but it rarely causes me much distress. That has changed somewhat. Oh my holy, my back aches by the end of my shift. I stretch and touch my toes as much as possible, and it has gotten a little better as I've gotten used to being on my feet. Ibuprofin helps, but not all the way. Note to self: find a massage therapist.

I haven't had any hilarious customers (nor would I blog about specifics here- I like being employed, thanks), although I have fielded some oddball requests. No, I will not make you sugar cookies using your own cookie cutters, and no, I really don't think the slice and bake kind are too much work. But aside from that, no royal jerks and so all is well.

Physically, the job is pretty demanding. The ovens in the back kick out a lot of heat, as do the refridgerated cases, so I sweat heaps. The upside is that I almost never have to go to the bathroom in spite of drinking 3 bottles of water during my shift. One would think that the demands of my job would have made me unusually hungry, but it really hasn't. I don't know whether this is because my hunger sometimes doesn't strike, that I'm eating by osmosis, or that it's stinking HOT back behind the counters, but I don't really get hungry at work. I have gotten hungry after my shift, perhaps because I'm sitting and my brain has the opportunity to process those little stomach signals.

Being around food--specifically food that I would have found extremely distressing during the height of my eating disorder--hasn't really been an issue. I don't in general feel comfortable sampling the overpriced baked goods I'm selling, in part because I fear my potential nibbles adding up into pounds of weight gain, but also because I don't know how to make it work with my meal plan and I don't know how to work it out with my mom (the general rule is that if someone doesn't see me eat it, I didn't eat it). I realize that this is part of the legacy of an eating disorder, and I don't blame her for being cautious, as I've run wild with these excuse in the past. But next week we will be discussing it with TNT, so that's good.

There is a nutrition information binder for the items we sell, and I was a little shocked to realize that the desserts weren't as high-calorie as I had feared. A few caught me off guard, but most of them were easily workable into my meal plan. The irony is that I would be not overly anxious having a cupcake, say, for a snack, it's just that I worry about having a bite of a cupcake. And not just "a bite" but I fear that that one bite will turn into two and then half the cupcake and then the whole thing and then I'll be applying for jobs at Sea World. So I don't know how to account for that one bite on my intake for the day. Logically, the solution would be to tell myself that it's just one bite, but we all know that EDs aren't logical, so we may as well drop that pretense.

Overall, this job has been a good thing. I am a lot more comfortable just being around food compared to when I started, and I'm able to start contemplating incorporating bakery items into my daily intake more often (albeit only after I looked at the nutrition guide, but whatever). None of my co-workers talk about dieting and weight loss, which is a huge relief, and I really like everyone I work with. No one there has called me "Captain Cupcake," but one of the bakers calls me Pookie. The irony is that's my nickname for Aria so I keep looking around for a tabby cat whenever I'm called Pookie.

The steady income helps with my stress levels, as does the fact that I will have health insurance on June 1 and can cancel those COBRA payments. I think I can do a preliminary guess that this job will work out just fine. I keep wondering whether I should tell management they hired an ex-anorexic to work in the bakery. Oh well. At least they don't have to worry about me stealing stuff out of the case!

We all made it through another week- hallelujah! And now, as part celebration, part brain candy, is this week's Sunday Smorgasbord. As usual, I have collected a bunch of links over the past week that encompass the good, the bad, the unusual, and the interesting in the ED world. You can decide which is which for yourself!

Do you have "perfectionitis"? (I do).

Body Dysmorphic Disorder: When your looks take over your life

People with the binge/purge AN subtype present a very different profile of appetite regulatory peptides when compared with the restricting subtype

Addicted to Fat: Overeating May Alter the Brain as Much as Hard Drugs

App-orexia: can smartphone applications be bad for your health?

The Stigma of Obesity (op-ed in the Denver Post)

Social Networks a Lifeline for the Chronically Ill

Randomized controlled clinical trial of yoga in the treatment of eating disorders

Weight ain't about exercise

Acceptance and commitment therapy versus cognitive therapy for the treatment of comorbid eating pathology

Comfort Food for the Wounded

Caloric restriction leads to high marrow adiposity and low bone mass in adolescent mice

The development of satiation in Bulimia Nervosa

Loneliness is something I have always struggled with. I was never friendless, but I was frequently lonely. Primarily, I felt like I was somehow freakish, and that no one understood me and no one ever would. I was convinced that other people didn't really like me--they merely tolerated me. This, combined with social anxiety, made me feel like the ultimate outsider. It sucked, and I knew it, but more to the point, I didn't think I could do anything about it. I was weird and that was that.

This basically meant that loneliness and I got to be pretty good friends. I usually coped with the feelings by reading (friends made out of words and paper!), by working at school or at other part time jobs, or by telling myself that I loved being by myself. The last one was and is true--if I don't get my "me" time, I start to go nuts. The second I was able to stop having a roommate, I did. I would just as soon live in a roach motel as have a roommate. But, alas, it doesn't mean I don't get lonely.

ED as a loneliness "cure"

Eating disorders are filled with paradoxes and ironies, and the "loneliness factor" is just one of them. My eating disorder made me lonelier than ever- I couldn't stand to be around people because they did odd things like eat and sit down and laugh. Also, friends got in the way of the eating disorder, and so I isolated myself even further. File under: vicious cycle.

Although I was more lonely than ever, my eating disorder made the loneliness feel better. It was good I didn't have friends because then no one would comment on my shrinking frame and empty cupboards. It was good I didn't have friends because then no one would interrupt my exercising or my purging. It was good. It really was.

Back in the summer of 2001, when the AN was picking up steam, I was planning on spending the summer at the Centers for Disease Control and Prevention in Atlanta, Georgia. However, this was the first time I was really on my own, living in a place where I had no real friends and essentially didn't know anybody. I had spent a semester in college studying in Scotland, but I knew several people from my school who were going at the same time with the same program. Living in a dorm meant that I was kind of thrown in with people. But Atlanta was different. I had my job, yes, but I also had lots of time to myself. I remember worrying about getting lonely, and I also remember my mom expressing her worries about my impending loneliness to me. I told my mom that I would meet people, my cousins were only 30 minutes away, I shared a sublet with another girl. But I distinctly remember thinking that it will be good that I don't have friends because then no one could make me eat.

Thus it was that my eating disorder made loneliness feel less awful. See? All of this alone time was fantastic- I could stare at cookbooks and exercise like a fiend with near impunity. If people were around, I knew my disordered habits would be recognized and I would once again become Carrie the Freak. The irony is that I pushed away the few good friends I did have because I didn't want anyone to get too close. It was so easy to do this in the eating disorder, both because of the nature of the ED itself (you feel compelled to engage in some pretty bizarre behaviors and you also feel compelled to conceal those behaviors from those around you), and because the ED made it easier to let them go. It didn't matter- I had my eating disorder. What more did I need?

Of course, recovery has meant coming face to face with those feelings of loneliness. Although I'm probably less lonely now that I was in the depths of my eating disorder (as measured my interaction with friends and family), it feels worse because I don't have the ED to "justify" my loneliness. There's nothing to take away the sting and burn of wanting to catch a movie with someone and having no one to ask. At most I can tell myself that it's fine I don't have many friends because at least then I can fit in a much-needed nap when I need to! I know the eating disorder doesn't make me any less lonely, it just makes the lonely hurt less. It's so easy for me to slip back in old habits when left to my own devices--in part because they are almost habitual after all these years, and in part because I need people to help drag me out of my eating disorder. The times I have done better in recovery are those times when I have made the effort to be social and reach out. I don't know which way the relationship works, but I know that being more social and doing better in recovery are linked.

Recovery has also meant a shift in how I perceive myself. As much as I'm an introvert and love my solitude, I've had to accept that I'm also a people person. I need social interaction just as much as I need a quiet sanctuary to escape from the said social interaction. Figuring out what to do about my loneliness is another matter entirely. One of my tasks from my therapist this week is to identify some groups or classes that I can attend which might interest me. Common interests go a long way in helping people make new friends.

I realize that even people with no eating disorders can suffer profound loneliness, and it would be silly for me to expect that recovery would mean I would never be lonely again (though wouldn't that be nice!). But I do still miss how easily the eating disorder was able to remove the sting and burn of loneliness and just how much it hurts.

I have massive anxiety issues. It was never overtly obvious when I was younger--my anxiety appeared more as irritability (my parents referred to me as "Grumpy Bear" from the Care Bears) and a nasty temper than out-and-out anxiety. Even through high school (and the appearance of a clinical anxiety disorder), I always thought I was more crotchety than anxious. It turns out that my irritability directly reflects my anxiety--when I'm super anxious, the world just grates at me and every little thing ticks me off.

I'm getting better at understanding just how much anxiety pervades my life. That's a start. But what I still struggle with is actually coping with the anxiety. Which brings me to my next roadblock to recovery:

Anorexia as an anxiety lessener

When I was in college and my AN just emerging (no one, least of all me, had a clue what was going on), I was also struggling with a resurgence of OCD and other assorted anxiety issues. By this time, I was seeing a therapist for depression/anxiety, and had recently started an SSRI. However, I still had plenty of freak-outs and moments of complete panic. So my MD gave me a small prescription of Xanax (a benzodiazapine) to help with these moments. There was a problem, however. The pills worked and help calm me down enough to be rational, but they also zonked me out, which left me no more functional than I was before.

Not surprisingly, as the AN kicked in to higher and higher levels, I found that not eating did a rather fine job of taking the edge off the anxiety. It didn't leave me quasi-comatose, and I got to feel like I was "accomplishing" something (ie, losing weight, eating "right," exercising, etc).

Even during my last relapse, I was aware that I should probably start eating more, that eventually my return to AN wasn't going to end well for me. I found myself frozen for a number of reasons, not the least of it was fear of weight gain and fear of change. But one of the biggest reasons I didn't want to start eating again was that I knew the anxiety kickback was going to be awful, and I just couldn't face it. With the ED, I didn't have to agonize over what to eat, or what to say or do (as long as it involved not eating and enough time to exercise, I was just fine). The added fact was that anorexia served as my trump card, which dulled the anxiety about everything else. Because even if everything else went to pot, at least I could be anorexic, right?

Recovering from anorexia meant giving up all that. It meant giving up my "virtual valium" and my go-to anxiety coping skill. Recovery hasn't, alas, diminished my anxiety any. I'm still just as bad as I ever was, only now it seems worse because I know the feeling is anxiety and not just me being, well, me. I have probably tried everything imaginable to help with the anxiety, from yoga to meditation to stress balls. I need an arsenal because not all coping skills are appropriate for all situations--I would look pretty stupid doing downward dog in the middle of the bakery. Ditto for crocheting a scarf. But I can use deep breathing techniques and I can remind myself that I have good problem solving skills. I can stash a stress ball or some Silly Putty in my purse or pocket. And I think learning to accept the inevitable anxiety will help me go a long way in decreasing the distress it causes me. At this point in my life, my anxiety isn't going anywhere. My mind tends to come up with ridiculous alternatives, and I'm not all that good at shutting down my brain. That's just the way it is, and I can accept that in a "Boy aren't I screwed" sort of way, or I can accept it in a "Anxiety hasn't killed me yet, so I can manage" sort of way.

This particular roadblock wasn't on my list of cons to recovery, but I just realized how relevant it was.

(Not) feeling hungry

As I've started my new job, I've noticed that no matter how many hours I go without eating, I don't get hungry. There are any number of factors to that, not the least of which are I'm really busy, I'm around food and so "full by osmosis," and that it's hotter than Hades in the bakery. When I get done with work, my hunger cues return to their post-ED norm. But at work? I don't feel hungry. I just don't.

This makes it really hard to eat my dinner and snack when I'm not even hungry. The ultimate problem is that I feel I have to rationalize my eating. Maybe it's that someone is watching me, or that I want to at least pass for normal at a group luncheon. Or maybe it's that I know I'm going to pass out if I don't eat something quick, even sometimes if my hunger is gnawing at me and I know beyond all reasonable doubt that I need to eat something. But eating when I'm not hungry (and no one is watching me)? I feel so absurdly guilty. I tell myself I don't need this sandwich, this piece of pizza. I don't. I'm not even hungry! Why should I eat?

Why, indeed.

It's easy for me to say things like "An eating disorder may mess up your hunger cues so don't rely entirely on them," but it's another thing entirely to live this statement. Much of my treatment involved schooling me in the theory and practice of intuitive eating. For those who aren't familiar with intuitive eating, the premise goes something like this: eat when you're hungry, stop when you're full. When I was freaking out about weight gain, my dietitian told me that as long as I ate when I was hungry and stopped when I was full, I wouldn't gain weight.

I don't blame her for making this statement (it is both true and useful), but it also didn't account for all of the times when it is time to eat but I'm not hungry. It feels somehow wrong to eat (yes, even after all of this time), and to eat when I'm not hungry seems almost heretical. Before the AN struck, my appetite was just fine. I wasn't a huge eater, but I got hungry rather predictably and all was well. I know that all of these years of having this eating disorder have probably messed that nice little system up. Maybe it will come back, maybe it won't. It's certainly not a reason to throw in the towel and give up. I need to work with my body, as it is right now. And that might mean eating when I'm not hungry or eating at times that I haven't designated as "meal" or "snack."

Part of this, too, is breaking all of those rigid rules I had for so many years about what eating was acceptable and what wasn't. It's hard to trust that my body won't tell me it's hungry when it doesn't need food, and then to hold off on trusting it entirely to tell me when it is hungry. What I need is a system to help me eat when I need to and flexible enough to accommodate everyday life.

Let me subtitle this blog post as: Excuse me while I jump off a cliff.

Whatever your feelings on the passage of the Health Care Reform Bill this past Sunday (and I have many of them), I read the following in an AP Newswire article this evening:

A requirement tucked into the massive U.S health care bill will make calorie counts impossible for thousands of restaurants to hide and difficult for consumers to ignore. More than 200,000 fast food and other chain restaurants will have to include calorie counts on menus, menu boards and even drive-throughs.

Like I said: excuse me while I jump off a cliff.

My annoyance and irritation at this is mainly related to the fact that all throughout my recovery, my treatment team has drilled into my head that I shouldn't be obsessively counting calories, that my body doesn't need to count calories in order to maintain a healthy weight, and that one meal out is one meal out and if I want to have a burger and fries, I should have the burger and fries. Dammit. So if what my team is telling me is true, then what the hell is this push for calorie labels on everything?

Do I still count calories? In a more existential sort of way, yes. I am acutely, painfully aware of how many calories are in the food I eat. I might not always tally everything up like I used to, but I'm aware. I remain very wary of restaurants because I don't know what's really in the food I'm eating. I don't know how it was prepared, and I don't know exactly how many calories it has or what ingredients were used. Generally speaking, my tactic has been to order the item on the menu that seemed like it had the fewest calories. I'm pretty good at this. It's still my default menu scanning effort- any butter or cream sauces mean "loaded with fat," fried is also bad, sauteed could be dicey, broiled or grilled is okay, pasta and cheese are not good...and on and on it goes.

Yet again, my treatment team has tried to convince me that I don't need to scrutinize the menu for "hidden" calories and the minutiae of how my dish is prepared. Does it sound good? Okay, then.

The idea with placing calorie counts on the menu is that they will (in theory) change what people order. (For the record, research shows that it really hasn't changed ordering habits.) Taking the idea further, the idea is that if people knew how many calories were really in that dinner they ordered, they would order something different. Which, okay, fine, but shouldn't your criteria for what to order include a little more information that just calories? Are we really that stupid that we need to be (ahem) spoon fed our health and calorie information like this?

If some of my friends and relatives are to be believed, this healthcare reform bill may have saved us from dying of TEH FATZ only to help us die of TEH SOCIALISMZ. I'm not necessarily anti-government, but I'm just scratching my head over the wisdom of this idea. Our culture is more obsessed than ever with food and weight, and that hasn't seemed to change our average BMI by very much. And really, if the only reason people were fat was because they were stuffing their gullets with Big Macs at McDonald's, then I think we would have figured that out.

Another issue is that this law is aimed at chain restaurants, which tend to be (on average) cheaper and more affordable than swanky, upscale joints. Research has already shown that the higher your socioeconomic status, the lower your risk of obesity, and a Scientific American article last week pointed out the connection between obesity and food stamp recipients. In a sense, these rules imply that poor people are just too stupid to figure out what (and how much) to eat. Maybe eating fast food is the lack of better alternatives. Maybe it's being too damn tired to cook. Maybe it's all the food your kids know because it's the only restaurant in your area. Regardless, simply adding labels to the menus won't help if there's nowhere else to eat.

I'm just...annoyed. Irritated. And unsure what to make of it all.

So here's a confession that probably won't surprise most people with EDs but most people without EDs will find it baffling: I miss the endorphin highs that come with undereating and overexercising. I miss the psychic lightness that makes me feel disconnected to this life and this world. I do. I miss it.

Of course, to wax nostalgic about the 0.1% of the eating disorder that was physically pleasant would be to completely ignore the other 99.9% that was pure hell. But our brains are good at ignoring such technicalities and the fact remains that I miss those endorphin highs. A lot. I don't miss being so weak I could barely get out of bed, or nearly collapsed after I finally finished exercising. I didn't mind it then, because it was a sign that at least I didn't eat too much. But then there were those fleeting moments when I felt lighter than air, when I had just slogged through another marathon exercise session and felt so freaking good, when I realized I hadn't eaten for Lord only knows how long...those moments I miss.

The endorphin highs aren't a major one of my roadblocks to recovery, but it's part of it, and so I am blogging about it. On average, I feel so much better mentally and physically now that I am in recovery. Yet the problem remains: I still haven't found anything to match those endorphin highs. I remember in my high school health class, we got a handout on "100 Natural Highs" that didn't involve drugs or alcohol. Which was nice and all, but even little ol' innocent me could see that blowing the fuzz off a dandelion was a very different thing than shooting up heroin. It's fairly similar here. I do loves me an afternoon nap, but it's not a replacement for an endorphin high.

Part of me thinks I should just stop looking for a replacement. That maybe the problem is my need for the endorphin high rather than the inability to find that high in a non-self-destructive way. Maybe, too, the giddiness of the highs were exaggerated by the fact that they existed against a backdrop of misery.

Over the past few months, I've been revisiting some of the foods I used to eat as a kid and had fantasized about for years, fantasies fueled partly by starvation and partly by nostalgia. (Bear with me- this has relevance to what I'm talking about, I promise!) So I've started sampling some of those foods again, treats I see in the grocery store or hear maligned in the media. Some of them are as good as I remember (Swiss Cake Rolls, anyone?) but many of them really aren't. For the most part, I haven't rated these foods as gross/icky/otherwise inedible, but the attraction just isn't there anymore. I pass these items, think "That's nice," and don't think about it much anymore.

Perhaps one day I'll think the same way about the starvation and exercise highs. (See- I told you the above paragraph was relevant!) I'll be able to look at those highs and think "That was nice while it lasted, but my tastes have changed, thanks."

This week's smorgasbord is going to be a little shorter than usual- I worked a full shift today and yesterday and I am falling over with exhaustion.

The Bananas of Slip/Lapse/Relapse Prevention

Anti-Obesity Drugs Unlikely to Provide Lasting Benefit

Suppressing emotions increases desire to binge in women with BED

Depression moderates sociocultural influences on ED symptoms in adolescent females and males

Unstable emotions and binge eating in women with bulimia (from Psychotherapy Brown Bag)

Free webinar on the media and mental health recovery (via The F Word)

Pledge for Wellness: National Call to Action for Wellness of People with Mental Illness

When a parent has an eating disorder

Thin Wallets, Thick Waistlines: New U.S.D.A. Effort Targets Link between Obesity and Food Stamps

Body's anticipation of a meal can be a diabetes risk factor

Allocentric vs. egocentric frame of reference in body perception in anorexia

BBC News: Why Diets are Doomed to Fail

And, just for some random fun: The Sound of Jelly Wobbling was recorded for the very first time in 2008

Tomorrow I will return with another one of my Roadblocks to Recovery posts!

This is another post in my Roadblocks to Recovery series. It's closely related to yesterday's roadblock (ED as a trump card) but also different enough that I think it's worth its own post.

Without ED, I will just be "average"

My height is average. My weight is average (I'm small but solid). These things are fine, and I can (mostly) deal with it. Well, the first part of it. But heaven help me if I ever feel average.

Like so many things that happened with my eating disorder, much of this thinking process started with my academic life, long before I showed any signs of ED. I had to be "The Best." I wasn't a narcissist by any stretch of the imagination, but I had this competitive spirit. The darker side of that competitive spirit is that if I wasn't "The Best," then I sucked at whatever it was, and I may as well go home. My mom always said that only one person could be the best, and I remember plaintively wailing to her on more than one occasion, "So why can't it be ME?"

A few examples: in grad school, I had two exams in my immunology class. On the first exam, I scored at roughly the class average, which before the curve was around a 71% (this was 3 years ago, and I still remember it!). I was horrified and almost devastated--I had a therapy session afterwards and I sobbed about it and my poor therapist just handed me tissues. I was determined not to repeat this on the last exam, so I studied for weeks. All I could think of were the other people in my class who had surely done better than I. It never occurred to me that an equal number had done worse. For the several days before the exam, I barely slept and I was physically ill from the anxiety. My goal wasn't just to do better (which would have been a marginally decent goal), but to break the curve. Which I did. I was exhausted and burned out, but I did it. And I felt okay about myself, at least for a short while.

Even recently, I was playing Dominoes with my parents and some of their friends, and I was just so keyed up while we were playing. Even though I loved everyone there (I refer to these people as "Aunt" and "Uncle") and I know they didn't give a hoot about who won, I was terribly afraid that I wasn't going to win. I didn't. I got second place and I still walked away disappointed because I was utterly convinced that only some strange luck had saved me from last place. I didn't win, and that was all that mattered. It's why I don't like keeping score at mini-golf or bowling or even Pictionary. Because I rarely win, and so I frequently end up hating myself (yes, over not winning a game of Pictionary).

It goes something like this: my drive to win isn't so much from the joy of winning. My drive is from a fear of failure. This drive is essentially perfectionism, distilled to its essence. Of course, my eating disorder wasn't just extreme perfectionism- I wasn't "Starving for Perfection" or "Dying to be Thin." But the two are tremendously and inextricably linked.

The anorexia made me feel special, somehow. It made me feel like I was "The Best" when I was starving and over-exercising and losing weight. If I found out that anyone had eaten less than me that day (food poisoning, their own eating disorder), my brain flew into a tizzy and I felt compelled to exercise off every extra calorie or purge what was left in my system. Eating more than someone meant I wasn't "The Best," and if I wasn't "The Best," I was just average. My abnormally low weight played a role, too. Although I never fully bought into the (wrong) cultural idea that thin people are inherently "better" than those who are heavier, I was rather aware of this idea and it played a role in my ED. If I was the "thinnest," then I was "The Best." If I gained weight, I was only average, and average, as I've said before, is not something my perfectionistic brain likes to contemplate.

Recovery, of course, meant eating more and gaining weight. It meant extracting myself from my idiotic mind games surrounding academics and food and weight. And this is where it gets tough. Because this mindset is so ingrained and it seems rather rational in the moment. The underlying issue, if you really dig deep enough, goes back to really low self-esteem. Why else would I need a trump card or so deeply fear being average if I really thought I was a good enough person? It's hard for me to accept that "average" is just fine, because I fear that if I'm not "The Best," then I'm nothing. I know that what makes me special isn't my being "The Best" at not eating or losing weight, and that I'm still special even if I'm average in every way. I just need to figure out how I can value myself being average and letting go.

One of my therapy assignments this week was to write a pro/con list for fully recovering from my eating disorder. The idea of identifying the "cons" wasn't so much to figure out whether I should bother recovering, but more to identify the roadblocks I was likely to encounter on my way to recovery. I had quite a few cons, and it occurred to me that by addressing these issues head-on, I would probably have a better chance at recovery. So if recovery were a road, then these issues would be my roadblocks.

I thought that it would be an interesting or at least useful idea to address each of these roadblocks in its own post. This was also motivated by the fact that lumping everything together would make a novel-length post. I figured I would start out with the most significant of these roadblocks, which is:

Anorexia as my trump card

What in the hell do I mean by that? It goes something like this: I was good at losing weight and, even more importantly, I knew it. No one needed to tell me this. I'm aware that I'm smart and that I'm vaguely musical, but I'm only aware of these things because people have told me. It's not an internal state. So when I realized on my own that I was good at losing weight, it was the first time I remember feeling confident in any of my abilities (short of guzzling coffee at breakneck speeds). It was also the first time when I approached a task with an attitude of "Yeah, I can do this!"

The irony is, of course, that anorexia was a massive wrecking ball in my life and made me doubt my other abilities even more. But I was still good at losing weight. I was still good at eating less than anyone else. I was still good at exercising more. There was that. So the eating disorder essentially undermined all of my confidence in myself except where it came to my weight loss skills. I was Carrie the Weight Loss Wonder Goddess.

It's probably not surprising to learn that I began to use my anorexia as a way to feel better when something went wrong in my life. Get a bad grade on an exam? At least I only ate X calories. Get turned down on a job interview? It's okay- I've lost X pounds since the interview. F*ck the job. Get criticized by my boss/a friend/a family member? Whatever. I exercised for X hours and all is well with the world. No matter how badly I screwed up, no matter the disasters that might happen, whatever, at least I knew I had the anorexia. And the anorexia propped up what little was left of my shattered and broken self esteem. In other words, the anorexia functioned as my trump card--it made everything else much less relevant.

Now I'm left questioning and wondering- what the heck am I going to do without my trump card? How am I going to make things suck less?

One obvious answer would be to learn how to deal with the suckiness.

Another obvious answer would be to shore up my pitiful self-esteem such that bad things happening didn't mean that there was something wrong with me, that I was a bad person, or that I was doomed forever.

The thing is--I miss my trump card. I miss not knowing that feeling better is only a skipped meal away. I miss the self-confidence (however shallow and transient) that came with knowing at least I was good at something. Just one thing. It was my escape hatch, as there's no better way to escape from life than to be so starved you don't really know what's going on. It was my parachute, my Plan B. I've long since rid myself of the quasi-romantic notions that anorexia was wonderful and it helped my life and that it was all it was cracked up to be. Because it wasn't. Not by a long shot. But it was still there.

And I guess it still is there. It hasn't disappeared. I still know I'm "good" at it. It's just hard as I see through the lies and delusions of anorexia and have yet to find something to replace it.

Tomorrow's post is:
Roadblocks to Recovery: On Average

The past few days have been a little on the overwhelming side. Nothing to do with the eating disorder as much as it has to do with everything else.

It started with the realization that the COBRA health insurance I was buying from my old employer was $100 more each month than I thought, bringing the total up to almost $700/month. I had got a notice in the mail saying my account wasn't paid up, so I called the 800-number and talked to a girl who sounded all of 18, max. When she told me the reason why (I had been billed for the wrong health plan) and then told me the monthly rate, I asked her, point blank, "Are you shitting me?!?"

No. No, she wasn't.

I had been looking for a part-time job in the hopes that I could find one that offered health insurance. I really couldn't. Now with the cost of COBRA, I knew I had to find a full-time position. I had interviewed for a part time position at a local gourmet grocery store, and I called back to see if they had any updates. In my conversation, I realized that the store considered full time anything over 30 hours/week, and that came with health insurance. It was pretty much just the solution to my problem.

Anyone care to guess the department in which I was hired for said full-time position?

That's right: the bakery.

I'm not doing any real baking, more of a customer service type of job that happens to be in the bakery. When I thought about working around food, I felt no real anxiety or apprehension (it felt the same as if I were going to be selling sunglasses), nor did I feel a thrill of excitement like an alcoholic working in a bar. If things go to shit, I'll re-evaluate. Until then, I have a pretty okay feeling.

So just call me Captain Cupcake.

I also started work on my first official freelance writing assignment for a geology magazine, and played whack-a-mole for several days working on that, plus some even greater angst from another writing project that is driving me nuts. So with all of this happening, my anxiety has been off the charts. My foot might very well tap itself off my leg. I feel better today- still unusually anxious (even for me!) but at least I'm not wanting to claw out my own eyeballs.

I have to do my work orientation in a few, so I need to grab some lunch before I head out.

What do you do when you feel overwhelmed (that's not ED or otherwise harmful)?

I'm guessing I'm not the only ED person to struggle with this thought: that recovery somehow means giving up, that it somehow means failure. Failure and I? We don't mix.

It's odd- my most spectacular failings have not only occurred in this past decade, but they've also been the direct result of my eating disorder (ie, being basically kicked out of school, placed on medical leave at work, having left more jobs than I care to count to seek more treatment). And it's true, these things do make me feel like a failure. Many of my friends have careers and children, and I'm living with my parents. Thinking about this doesn't exactly lift my self-esteem.

Yet the problem remains: if the eating disorder has been the one thing that has uniformly screwed up my life, how can recovery be a failure?

The answer? I see my own recovery less an embrace of the future and more of a throwing in the towel and admitting I couldn't hack it.

Who's shocked that this attitude has left me less than fully recovered? Anyone? Anyone?

The odd thing is that I don't view other people that way- I get excited when I learn someone else has kicked the ED to the curb, or has finally decided to seek intensive treatment. I can see it's such a positive step. But it's almost as if my Puritan Work Ethic has gotten twisted into the eating disorder. That same work ethic that allows me to study and write for hours on end, that has kept me out of blinding debt, is the same ethic that says "Don't give up now!" Silly Carrie- quitting is for babies!

I love the quote that says "Quitting something that is bad for me isn't giving up," although I could never quite convince myself of it. I'm not sure quite how to see recovery as something other than quitting or giving up. I can tell myself all of the things I would be able to do without the stupid eating disorder following me around, and that's something (that is, admitting that the ED is actually preventing me from, I don't know, living my life), but I still feel SO TREMENDOUSLY GUILTY for "giving up" and gaining weight.

Maybe, in the end, I won't be able to convince myself that recovery didn't somehow involve "quitting" just before I showed everyone how good I could be at this anorexia thing. It helps to know that I'm the only person that thinks this, but one thing I haven't learned is that you can't have it all. There are always choices and trade-offs. Give up food and free time and sanity to gain a semblance of control over your life. Maybe I'm intellectualizing this, but it's fairly simple math- is the price of whatever worth paying?

So yeah, I'm quitting anorexia and giving recovery a shot not because I'm a quitter and just gave up, but because I realized that anorexia just wasn't worth it anymore. It's like saving for a new car to realize that your old one works just fine, as soon as you get the brakes fixed, and you would rather use the money on a trip to Europe. Not quitting. More like repurposing. For me, it's repurposing my time and energy and life to something that will be more rewarding.

Next task: find that something...

In my recent post on living life with an active voice, my friend Angela pointed out that recently, I had begun to post more authentically, and (this is perhaps what stood out the most for me) I wasn't intellectualizing everything and hiding behind it. Intellectualizing everything is a habit I've had for years. Everyone knew me as The Smart One. I wasn't good at sports, I wasn't good at art, I was decent at music but far from the next Mozart or even American Idol. I also wasn't really bad at anything- I didn't achieve renown for being the Bad Girl or She Who Sucked At [fill-in-the-blank]. No, I was the Smart One, and I fell into the role rather eagerly. Social interactions were never my strong point, but I could handle brainy stuff.

Not surprising to think that this followed me into my eating disorder.

I thought a lot this past decade about recovery and anorexia. I did research. I read books. I talked to experts. And then I thought some more. I never really lacked insight--but I did lack skills for reaching out to others, for shoring myself up in ways that didn't require extensive brainpower, for dealing with the emotional messiness that accompanies an eating disorder. Simply put, I tried to think my way out of my eating disorder.

An oh-so-helpful reviewer of my first book wrote that I was doomed to relapse because I intellectualized everything. Besides the fact that I had relapsed already by the time they posted their comment, my basic response teetered between "You don't know shit about me" and "So I intellectualize everything? So what?" Yes, the spirit of the comment wasn't necessarily friendly or helpful, but the person did have a point. What I struggle with is how not to intellectualize everything. Outside of the eating disorder, I'd have to say my intellectual side has served me rather well.

But there's still that eating disorder. It's still here. Maybe not as severe as it has been, but it's here. I don't know what role my constant intellectualizing plays in my ongoing saga, nor am I exactly sure what "intellectualizing" really means. I know that when I want to learn about anger, say, or depression, that I look it up on Google or in PubMed. I can tell you about brain abnormalities and neurotransmitter deficiencies and excesses, but here's the thing: when I get mad or sad or anxious or any number of emotions that make me feel ick (read: like using ED symptoms), I don't know what to do. One of my good friends, who happens to have severe anxiety, asked me how I coped. I blinked and answered: the eating disorder.

Anorexia was my ultimate intellectualization. I could justify anything in that state. I didn't have to feel; I barely had to exist. My body was beside the point. I saw starving myself as this battle of mind over matter. I could think my way out of any problem, because I could figure out a way to make Situation A turn into Result B, which was restricting and losing weight.

I need to stop hiding behind my brains. I know I'm smart, although I don't often feel smart. That's not the point. The point isn't to dumb myself down or to stop thinking about things. The point is to stop neglecting my emotional side (assuming, of course, that I have one! :). To do this, I'm going to focus less on blogging about research stuff and more on blogging my recovery and the issues therein.

I have loved blogging about the science of eating disorders, and I don't intend to stop forever. I also don't intend never to blog about research in the coming months. I often found it useful to use an interesting new study as a jumping off point to explore a new issue, frequently one I never thought about before. I also reserve the right to blog about super-cool, hot off the presses research if the mood strikes me. But for now, I think I need to start focusing on ME and MY recovery rather than research and outreach and awareness-raising.

I hope everyone enjoys this week's round-up of eating disorder related news, research, and other tasty tidbits. As always, please feel free to share your thoughts in the "Comments" section.

Risk factors, correlates, and markers in early-onset bulimia nervosa and EDNOS

Certain brain chemicals (neurotrophins) may modify age of ED onset and minimum BMI

Rates of food sensitivity vary by country

Weight-bearing exercise during dieting/weight loss doesn't prevent loss of bone density

Portions Uncontrolled: The New World of Binge Eating (despite Binge Eating Disorder being far from "new," I think it's a really good article on BED)

Is there an upside to depression?

The genetics of temperament

Be the first line of defense against eating disorders

Can humans taste "fat" just as they do sweet, sour, salty, bitter, and umami?

Worksheets and ideas for each stage of eating disorder recovery

Exercise helps smokers quit, and douse the cravings

Concerns about calorie counts on campus menus

No evidence for sugar addiction in people

Diet Switching Can Activate Brain's Stress System, Lead To 'Withdrawal' Symptoms

Last week in the scientific journal Nature, Peter Fiske wrote about the need for scientists to use an active voice in their writing and careers, rather than the passive voice. Writes Fiske:

When I was in graduate school studying geology and environmental sciences, many of my professors insisted that we students write our manuscripts in the passive voice: “This was done” rather than “I did this”. They reasoned that removing the agent from the description of the action lent an objective tone. As scientists, we stood apart from our work and encouraged others to critique it (rather than us).

Yes, I'm a writer. No, I'm not lecturing you about grammar.

The passive voice, as Fiske goes on to explain, permeates not only how people write about science but also how scientists approach their careers: waiting for something to happen to them, rather than making that something happen. Although Nature is geared towards scientists and Fiske's article was meant for the people who read Nature, I realized as I read his article that so much of my life had been lived in "passive voice."

I got an A on a test because the test was easy, not because I studied hard. My good grades had to do with the test being easy, rather than my working hard. I got internship placements because I put all the right words in the right places, not because I was a solid candidate. Ditto for getting into graduate school. These had nothing to do with me and my accomplishments, but more with my simply telling people what they wanted to hear. I had friends because there were few other options, not because I was friendly. I relapsed because life sucked, not because I didn't use better coping skills. Life really did suck, but I have to remember that the general suckage of life didn't cause my relapse. There were points along my path where I could have dug myself out and I didn't; eventually things progressed to the point where I really couldn't dig myself out. And I also actively reached out for help. My parents and treatment team did sort of "strong arm" me into recovery, but I also chose to go along with it.

Active voice. Not passive.

Some parts of life happen to us, whether it's a natural disaster or something else that's out of our control. Come to think of it, there's much of life we can't really control in an "active voice" sense. But that doesn't mean that life is a passive voice experience. Which includes ED recovery.

I have waited around for years for recovery to "happen" to me. I waited for the inspiration, for the "ah-hah" moment. I waited to feel like eating or gaining weight. I thought recovery would just happen one day, as long as I waited it out and kept my fingers crossed. It's been a rather rude wake-up call to find me struggling, still, so many years into this. Although time helps heal the wounds, time alone isn't enough.

I need to integrate more active voice into my recovery, identify more things for me to do and to work on, to take a more prominent and engaged role in my recovery rather than just waiting for things to "happen."

How do you use the active voice in your life? How about in your recovery?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So what does this have to do with anorexia?

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

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

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

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

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

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

(emphasis mine)

Can I hear a "Hallelujah, amen!"?

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

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

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

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

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

Appetite may be partly linked to germs in the gut

Treating daughter's eating disorder must involve entire family

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

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

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

Sorority Girls More Likely To Have Bad Body Image

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

Significant genetic influences on all forms of disordered eating

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

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

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

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

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

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

And last, but certainly not least:

Puddle the turtle has anorexia

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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