Exposure and response prevention

I'm going to indulge my geeky side here briefly, as I stumbled across a research article about the use of exposure and response prevention for anorexia.

The International OCD Foundation describes exposure and response prevention as:

The "Exposure" in ERP refers to confronting the thoughts, images, objects and situations that make a person with OCD anxious.

The "Response Prevention" in ERP refers to making a choice not to do a compulsive behavior after coming into contact with the things that make a person with OCD anxious.

This strategy may not sound right to most people. Those with OCD have probably confronted their obsessions many times and tried to stop themselves from doing their compulsive behavior, only to see their anxiety skyrocket. With ERP, a person has to make the commitment to not give in and do the compulsive behavior until they notice a drop in their anxiety. In fact, it is best if the person stays committed to not doing the compulsive behavior at all. The natural drop in anxiety that happens when you stay "exposed" and "prevent" the "response" is called habituation.

It's primarily used to treat people with OCD, but since there is an overlap in many of the symptoms of OCD and eating disorders--"The overlap between AN and anxiety disorders suggest a model of AN in which baseline anxiety features yield eating related fears, avoidance behaviors, and ritualized safety behaviors that promote the underweight state and the perpetuation of the disorder."--the authors thought that ERP, as it's commonly known (because if the psychotherapy community loves one thing more than couches, it's acronyms), might be helpful in relapse prevention. Their guess was right.

This blog post isn't about the study- I'm trying to stay committed to my pledge not to intellectualize my illness. But as I was in the bakery today, I was thinking about this study. Why? For one, I had lots to do and very few customers, which meant my mind was free to wander about. For another, I got offered a sample today, this time by the cheese people. I was offered a piece of queso manchego, and I took a teensy little piece. I didn't know if I would like it, and also that whole eating disorder thing I've been telling you about. The cheese lady asked me what I thought, and I nodded and said "Pretty good." And the cheese was. So the cheese lady said, "Here, have a bigger piece." I just about flipped the shit on that one--two pieces of cheese in one day?!?--but I also knew that my recovery depended on saying yes and so I did say yes and had the second piece of cheese.

Which is just about when I started freaking out. I had every imaginable thought running through my head, ranging from "Everyone is going to think I'm a PIG!" to worries about massive weight gain from a small piece of cheese. This is why I avoid samples, I thought, because it's so freaking stressful.

Once I calmed down a bit, I was able to talk myself off the ledge of oh-shit-I-ate-too-much and I got a wry chuckle out of how much exposure to my ED fears this job is giving me. And cue thoughts of the study I cited above.

Although I don't think an eating disorder is "about" control, I certainly would say that it's a major theme in many people's eating disorders, including mine. I did some exposure work with fear foods in the past, but that exposure was always on my terms. I made sure I was never in a situation in which I couldn't get out of eating. More than that, I did my damnedest to make sure that I wouldn't be in a situation in which I'd be offered food without my being aware of it (I fully expected to be offered hors d'ouerves at a cocktail party, or even a meeting over coffee, so I could "plan" or restrict accordingly if I couldn't get out of it). Even in the bakery, I still have control. No one is making me try things. I won't get sacked because I don't/won't/can't sample the eclairs or the cannoli. I could make up a dairy allergy, a wheat allergy, a calorie allergy to look less like a freak.* But I know that recovery means learning to live with offers of food without my fight or flight response kicking in.

So I said yes to the second (fairly sizable) slice of cheese.

Before you go patting me on the back too much, know that I had packed a string cheese with my dinner, and I substituted the queso manchego for the string cheese. If I didn't have an item that was quite so equivalent, I probably would have backed out. But I accepted the cheese and ate it and found that it was actually quite good- a lot like Parmesan but less crumbly and pungent. I didn't plan on having the cheese, I didn't know the exact calorie count, and I accepted a sample at the bakery--all of which are anxiety provoking things for me.

In ERP, the therapist usually asks you to create a hierarchy of anxiety-provoking tasks for you to accomplish, starting from the least anxiety-provoking to the most. And then you systematically begin exposing yourself to the items at the bottom of the heirarchy, and work your way to the top. Today's cheese incident was probably fairly low on the heirarchy- maybe not the lowest, but definitely not at the top.

And I ate the cheese. And I survived. I didn't restrict, I didn't purge. I am exhausted and frustrated (dude--it's cheese!), and I hate to think that this ERP party is just getting started, but I suppose it is what it is.

*"I'm allergic to food."
"So what do you eat, then?"
"Diet Coke, black coffee, and mustard."
Don't think I haven't seriously debated using this line! LOL


Cathy (UK) said...

I think that ERP actually makes a lot of sense in the treatment of many of the 'eating issues' of anorexia nervosa (AN) - unless, of course, the person genuinely does have an allergy/intolerance to certain foods.

You write that you don't think that EDs are about 'control'. I would argue that my AN was totally about control - of anxiety, and mood in general. I (subconsciously) attempted to control my anxiety (of life in general) by adhering strictly to self-created eating and exercise rituals/routines. I inadvertently discovered that by adhering to such rituals/routines, the world seemed a less chaotic and unpredictable place.

To make my first steps in recovery from AN 4 years ago (when in a very serious physical state) I simply had to 'bite the bullet' and eat more. But this meant changing my rituals/routines. I didn't want to die so I said to myself 'Cathy Just. Do. It = EAT.'. The anxiety associated with a change of my eating behaviour and eating more was initially unbearable. I felt utterly out of control of my thoughts and emotions. I felt almost suicidal. However, with continued 'exposure' (to a new eating routine) my anxiety levels dropped and I was able to gain weight + health.

Finding Melissa said...

Gosh - this post strikes some real chords with me but also seems like a fantastic opportunity for learning. I think that it can be hard, when you've been ill for a long time, for opportunities to test the boundaries to come up naturally. For me, People became so aware of my eating disorder, that they rarely offer me food and there is always a safety net. Experimentation, like you described, has taken place - but on my terms.

This is okay, but not the whole picture as it means that quite a lot of the fears and routines can persist. It seems, however, like the bakery is providing you with some brilliant opportunities for learning and seeing what happens, which is the thing that most helped me to recover. Will that cake really kill me?...nope, but you need to get over the fear enough to learn that. Is it okay to say yes?...yep, the world doesn't fall done and people don't look at me like I have three heads.

This is a real chance to prove the eating disorder wrong, and I think you're being fabulously courageous.

Anonymous said...

i wont lie i absolutely flip a shit in my head when i am exposed to stuff i dont mentally preplan or know about. like food wise if i know i will have to do something scary or out of sorts i like to KNOW and plan for it- exposed to it in the end or not- i like to have control. i still have bad "eating times" according to living by the clock and what other people think about when i should east but exposing myself to odd eating times has helped to!

Nichole said...

I've totally been there! I was at a pastry store with my grandmother and was offered a little piece of dark chocolate (probably about the size of my thumb). As I'm suffering from a relapse, I freaked out. This battle raged in my head, and I started thinking about the calories in it. I hadn't eaten much that day, 200 or so calories by 3pm, but the anorexia inside of me was screaming "NO, NO, NO." As I try to look like I eat around family, I took it. Instantly, I regretted it. It's a cycle that doesn't ever really stop, and I'm sorry you had to go through that. :( I'm very happy to hear that you're stiking to your recovery, though! Keep fighting!

Kim said...

This is a big issue for me! This is something that is still a struggle for me in recovery -- the unexpected eating situations. Like you said, I've done exposure work with fear foods in the past, but it was always in a very predictable, planned, controlled environment, i.e. The Pizza Outing, The Cake Challenge, etc. These were EVENTS! I did fine because I was prepared and I had worked the event into an acceptable frame of reference for me. What's hard are the spontaneous situations. We had a meeting at work the other day and there was pita and hummus there. Now, these are totally 'safe' foods for me, but because I wasn't expecting to have a snack at 5pm, I was a little befuddled when I was offered some (I said "no," by the way). I just don't like being caught off guard. Most people look at this as "ooooh, an unexpected treat!" but these situations are very hard for me! I'd say this is my biggest food recovery aspect right now. I might have to blog about this lately (and quote you!)

A:) said...

This describes the dilemmia of trying a fear food absolutely PERFECTLY. . .

It's funny how people with EDs have such similar thoughts. I could have written this!


Katie said...

I find this really interesting because I KNOW I would have related to it a few years ago, but digestive damage from my eating disorder means that I really do have a number of allergies now and find it very difficult to eat out or accept food from other people. I loved this when I was anorexic but now it's a pain in the butt, because I couldn't challenge myself with spontaneous food or traditionally 'scary' things like pizza. It really annoys me, and I don't say that sarcastically. I feel like this time in recovery is different, I have really got myself sorted out, but I can't have real freedom around food.

By the way, I feel a bit arrogant saying this (because you have a load of commenters and are not exactly likely to have noticed my disappearance), but I haven't been commenting recently because I've been insanely busy and not online much, not because of your changed format! I still read and find your posts really interesting :) I just thought I'd say that in case you thought you'd lost people when you started blogging about other things.

Angela E. Gambrel Lackey said...

Carrie, you wouldn't be you without a geeky side. :) (Written with much affection.)

It's funny, I was complaining to Dr. S today about insomnia and he insisted I should eat a piece of cheese before going to bed because it would help me sleep (the tryptophan). He never gives up, ha ha.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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