It's that time of the week again! Yet another random sampling of the latest ED news and research, gathered by me for all of your enjoyment. As always, I welcome your thoughts and comments.

Whole Foods says to employees "Weigh Less, Pay Less"

Jezebel broke the story that employees of Whole Foods Market who meet certain health biomarkers (blood pressure, cholesterol levels, and BMI) will receive at 10% discount on the cost of their health insurance.

Whole Foods CEO John Mackey explains the program in a letter, reproduced below. Apparently it's part of an initiative to reduce health care costs, which is interesting since Mackey is against the health care reforms that would actually reduce costs for all people.

Note that Mackey knows BMI isn’t a perfect measure of health, but at least it’s cheap! Even more fun, though, is the poster for the new Healthy Discount program, breaking down exactly what BMI range his minions need in order to get various discounts on his Tofu Pups.

If your BMI is above 30, you’ll get to keep the original 20% employee discount, but you’ll paying more than your thinner co-workers, who can knock as much as 30% off. Because if public health research has taught us anything, it’s that reducing people’s buying power totally makes them healthier. Stay classy, Whole Foods.

For some great analysis, check out Rachel's great coverage at The F Word and an interesting discussion by the parents of Around the Dinner Table, started by the ever feisty IrishUp.

Biological tests for mental illness

News that a research study had established a biological-based diagnosis for PTSD was covered by numerous news outlets last week. Scientific American had a decent summary here:

Diagnosing PTSD is not necessarily simple. Psychological evaluations for PTSD cannot always easily distinguish it from other mental illnesses, such as depression, or determine if a patient is over- or underreporting the symptoms. Now, a brain- scanning technique called magnetoencephelography (or MEG) could offer the first biological test to help specifically diagnose and treat those with PTSD. In a study published January 20 in Journal of Neural Engineering, MEG correctly identified 97 percent of patients that psychologists previously determined were suffering from PTSD.

...For 72 of the 74 patients previously diagnosed with PTSD, MEG scans detected a pattern of neural communications that was different from the healthy participants, but shared among the PTSD group. On the flip side, 31 of the 250 healthy patients had abnormal scan results.

As many of my readers can guess, I love the idea of a biologically-based diagnosis for what is, essentially, a biologically-based illness. But the blog Mind Hacks raised some very interesting problems with this study that wasn't covered by the mainstream media.

The study used a form of brain scan called MEG, essentially a high-tech form of EEG that picks up magnetic fluctuations from the brain's electrical activity rather than the electrical signals themselves, and found that the coherence of signals across the resting brain was reliably different in vets diagnosed with PTSD by interview, compared to healthy people without mental illness.

Crucially, the scan didn't pick out cases of PTSD among people with a range of mental illnesses, it just found a difference between people with PTSD and healthy people. But this is not a diagnosis, it's just a difference.

If you're not clear on this distinction, imagine that I claimed I found a new way of diagnosing malaria in under 2 seconds - I just measure body temperature and if the person has a fever, I decide they have malaria.

I hope you would point out that this is ridiculous, because people with flu can have fever, as can people with typhoid, mumps, dengue and so on.

My test would genuinely distinguish between people with malaria and healthy people, but in no way is it a diagnosis.

It's important to know both the advantages to these brain-based diagnoses and also their limitations. Certainly, this study represents an advancement in PTSD diagnosis, but how much of an advancement remains to be seen.

Forget Jenny Craig. Hit the Drive-Thru.

Abby Ellin's new article in the New York Times covers the ever-evolving diet trends. No need for gritty shakes or pre-packaged meals; the newest diet trend is fast food.

Christine Dougherty, a 27-year-old business consultant in Pensacola, Fla., thinks so. “I don’t like to cook, and I wanted to be realistic without changing my lifestyle too much,” Ms. Dougherty said. She began replacing her usual fast-food lunch or dinner with meals from the Fresco menu at Taco Bell, which consists of seven items — including burritos and tacos — each with less than 9 grams of fat, compared with, say, 30 grams of fat in the Stuft beef burrito on the regular menu.

Ms. Dougherty said that she ate there five to eight times a week, exercised more and — over two years — lost 54 pounds. By December 2009, she was the spokeswoman for Taco Bell’s new Drive-Thru Diet advertising campaign for the Fresco menu, which features Ms. Dougherty’s story in TV and print advertisements, and online. The company recently began offering the menu in its drive-through kiosks, and not just inside the restaurants.

...Some nutritionists suggest that consumers be careful of anything the fast-food business has to say about reduced-calorie, or healthy, options. “Even if they’re offering healthy fare, go into it with a wary eye — more likely they’re tricking you,” said Elizabeth Somer, the author of “Eat Your Way to Happiness,” and a registered dietitian in Salem, Ore. “The fast-food restaurants have not led the troops in healthy eating yet, so there’s no reason to believe they’re going to change their colors now.”

It seems to me that this is just another "Lose Weight Quick!" scheme. I could eat two Big Macs every day and lose weight, if that was the only thing I ate. It's not some sort of food magic, it's just a way to reduce your caloric intake. It's not been studied, it's not a long-term solution, it's just another trend. Frankly, the thought of eating Taco Bell several times each week makes me gag. I have never liked "Taco Hell" and it has nothing to do with the fat and calories of the options. It's just...ick.

Michelle Obama's anti-obesity initiative

In yet another short-sighted attempt to stem the "epidemic" of childhood obesity, Michelle Obama is promoting an initiative with a nice-sounding goal: "To put in place common-sense initiatives and solutions that empower families and communities to make healthy decisions for their kids."

Says Obama in an interview with USA Today:

Obama acknowledged the difficulties parents face. "It wasn't that long ago that I was juggling a full-time job with the round-the-clock role of being a mom," she said. "And there were plenty of times when after a long day at work, when the fridge was empty and the kids were hungry, that I just ordered that pizza, because it was easier. Or we went to the drive-through for burgers, because it was cheap and quick. And I wasn't always aware of how all the calories and fat in some of the processed foods I was buying were adding up.

"It got to the point where our pediatrician had to tap me on the shoulder and say, 'You know, you might want to consider making some changes in your family's diet.'

Because we all know that diets are really effective and have phenomenal long-term success rates. And it gets better:

Tackling the problem has been gaining momentum recently. On Monday, an expert panel recommended that physicians and other medical professionals screen children ages 6 and older for obesity and refer obese children to comprehensive weight-management programs.

Right now, there aren't enough weight-management programs for children, and those programs aren't covered by most insurance plans, experts say. The new recommendation may help change that.

Will they also cover the treatment of the eating disorders that are triggered by these health classes and anti-obesity hype? Even the president himself isn't immune to the fitness hysteria:

U.S. president Barack Obama has also in the past publicly voiced concerns about the habits of their children, saying that Malia had become 'a little chubby'.

Way to make your kid really freaking paranoid, Mr. President. Many kids put on weight right before puberty as their bodies' gear up for a growth spurt. It's neither problematic nor pathological, until we've made it that way.

I've noticed something interesting over the past few days. I recently returned to Michigan for a short visit (and a reminder why I moved down South with the sub-zero temps), and so I was wrenched out of my usual routines. Perhaps one of the most interesting realizations has been about body image. It's a big woe of mine, and it isn't made any easier by the fact that I can't shake the feeling that I'm a vain, vapid idiot because I constantly check my body in any reflective surface. A mirror, a pane of glass, a spoon, the toaster, the car door, you name it. The body checking is an OCD-ish behavior, and I get that, but I feel terribly emo when I keep whining "But I'm so faaaaaaaat!" I got so sick of constantly blathering on about how huge my stomach/butt/thighs were that I stopped journaling for about a year.

My body image still sucks. That hasn't changed.

What has changed is how much I care. I don't go out of my way to find reflective surfaces (or to avoid them, depending on my mood), though I do still check if I catch my reflection. Usually, I will look, wrinkle my nose, and then get on with my day. I still think about my body a lot, and I am often acutely aware of the layers of blubber that seem to coat my body. It's not fun, and I often have vague thoughts of a do-it-yourself liposuction with a couple of bendy straws and my Dustbuster. But these thoughts and perceptions don't rule my day. They're just thoughts. They come and--more surprisingly--they go.

I'm still rather conscious of the fact that my body perception is tremendously off. I met with several former colleagues, both of whom said I looked very healthy and rather thin. I wanted to ask them if they needed a new glasses prescription because there was no way I was thin. None. Yet I'm more perturbed by the fact that I still can't provide an estimate of my body shape and size than the fact that I feel like a [insert favorite large barnyard animal here].

This was much of the way things were before the formal onset of the eating disorder- I thought I looked reasonably ginormous, but I didn't think about it all too much. In more despairing moments, I thought to myself that I'm going to be a fat loser, so I may as well just accept it. But mostly, it didn't really bother me on a day-to-day basis, perhaps because I only ever saw myself as the "fat girl" so it didn't matter. The irony was, of course, that my height and weight both tracked at the 60th percentile, so there was no way I was the school heifer. But of the many things that generated teen angst and despair, my weight usually wasn't at the core of it.

And it isn't really anymore. My body is what it is. I don't have to like it--and I frequently don't--but I don't have the kind of blind seething hatred and desperation to look differently, either. I know this isn't the end of the "fat days" and the curses directed at my thighs. But it's not everything anymore, either. It's not worth the effort to change.

There was an interesting article the other day in the magazine Psychiatric Times about OCD in Egyptian Adolescents. Much of the article discussed how religion and culture can affect the manifestations of OCD, and I found these effects fascinating.

Writes psychiatrist Ahmed Okasha:

Previous Egyptian studies on psychiatric phenomenology have shown a prevalence of culturally determined symptomatology, where religion and prevailing traditions seemed to color not only the clinical picture of the condition, but also patients' attitudes about their disorder...The role of religious upbringing has been evident in the phenomenology of OCD in Egypt. The psychosociocultural factors are so varied that they can affect the onset, phenomenology and outcome of OCD. They can even affect response to treatment. The emphasis on religious rituals and the warding-off of blasphemous thoughts through repeated religious phrases could explain the high prevalence of religious obsessions and repeating compulsions among our Egyptian sample...The female gender is surrounded by so many religious and sexual taboos that the issue becomes a rich pool for worries, ruminations and cleansing compulsions in women susceptible to developing OCD.

(Emphasis mine)

It was the last sentence that really struck me, because it shows how culture impacts the expression of mental illness, and it enables us to look at the interplay without pointing fingers.

Here at ED Bites, I write a lot about biology. I spent much of my life in training to become a biologist of one sort or another, and I loves me some interesting science. This explains some of my emphasis on the biology of eating disorders (old habits die hard...), and some of the emphasis stems from the fact that the biological issues are, in general, much less discussed in popular media than the cultural aspects. This doesn't mean that I think culture is irrelevant; far from it. Your culture and your environment has a profound impact on who we become and what illnesses we may or may not have.

The religious atmosphere in Egypt doesn't cause OCD, but it does influence the content of your obsessions and compulsions, and the meaning you may attribute to them. Could living in a world where religious rituals reign supreme make you more likely to develop OCD? Perhaps. As Okasha points out, these rules certainly make a fertile feeding ground for ruminations and worries. And to someone susceptible to developing OCD, these feeding ground doesn't need much fertilizer for an obsession to grow.

I wish there were more articles looking at the intersection of culture and eating disorders in this way. In the stereotypical newspaper article about the pressure to be thin or dieting celebrities, these pressures are equated with causing eating disorders. And while that's not exactly true, that doesn't mean that culture is completely irrelevant. It appears that cultures where there has been less emphasis on the thin ideal, non-fat phobic anorexia appeared to be much more common than the Western fat phobic type. That doesn't mean there isn't a biological basis for body image distortion and fat phobia, just that it is only expressed under certain conditions. Recent research from Hong Kong has shown that as China has increasingly adopted Western ideas of weight control, the proportion of people suffering from fat phobic anorexia has also increased (Lee et al, 2009).

You can't win the fight of nature vs. nurture because it isn't a fight at all. That's just not how it works. Nature and nurture each have their push and pull on who we become, but it's not a tug of war and winner takes all. It's more of a dance, with both Nature and Nurture taking the lead at different times. If only this could explain why the heck I have two left feet...

Many of the recovery stories I read when I was first diagnosed with anorexia usually featured an epiphany for the now-healthy person. Usually, it went something like: "I saw a photo of myself and saw how bad I looked. I realized I was killing myself. So I started eating again."

If only...

My problem wasn't that I didn't know the damage I was doing--I could recognize it on a cognitive level, even if it didn't always have the same emotional impact--it was that I didn't really care. So my treatment stays came and went, and I went through the motions, but I was waiting for that Come to Jesus moment when everything would click and I could move forward with recovery. I said many of the Right Things, those profound statements that therapists just totally eat up- "I'm recovering for myself now!" "I'm listening to my body!" "Anorexia really isn't about food!" And so on. Part of me wanted to believe them, and a part of me probably did, but I was completely and utterly full of crap. In reality, I was still waiting for the lightbulb moment, that hallowed clarity, to see the meaning behind my behaviors and start the meaningful work of recovery.

Needless to say, I've never had an epiphany. My thinking has evolved over the years, sure, and I've certainly have some realizations, but no holy-crap-anorexia--is-stupid moments. Those moments are nice, and I'm not saying they aren't important if they happen, but they're often not the basis of a lasting recovery. I realized that anorexia often created more problems that it solved quite a few years ago, but that never meant I couldn't still be scared to eat.

I've stopped waiting for these sudden jolts of clarity and understanding. Perhaps my most important revelation is that recovery is based in the dogged repetition of recovery behaviors and not any masterful realizations. For so long, these recovery behaviors felt awful. I wanted to crawl out of my skin- I would even rake my nails up and down my stomach and legs because the feeling was so intense. Talking about my feelings, asking for help, drinking the Ensure, none of this felt normal or natural, and it definitely didn't seem to help. I didn't understand what I was supposed to be working toward. What was recovery anyway? And if anorexia made me feel better, how freaking bad could it be?

But I am learning that recovery behaviors can become more natural, just like learning a foreign language. When I first started to speak Spanish, I no doubt sounded like a demented gringo. After several years, I couldn't exactly speak like a native, but I didn't sound like a little girl playing dress-up in someone else's language. I eat. Day in and day out. I try to relax. I try to get to sleep at a normal hour. I talk to friends. I blog. These have created my recovery much more so than any mind-blowing realization.

There are no recovery shortcuts, no miracle elixirs, just the healing tincture of time and practice.

I have always been a bad sleeper. Even when I was a baby. Neither my brother nor I could get to sleep quickly and easily, though staying asleep was much less a problem. The odd thing is that neither of my parents have any sleep issues whatsoever. My dad doesn't know the meaning of the word "insomnia," and although my mom might have the occasional fretful night (thanks, anorexia!), difficulties in falling asleep aren't a problem for her, either. Whether or not my brother has outgrown his issues--to be honest, I've never thought to ask--I certainly haven't.

My breakdown shortly before I started this blog, that epic breakdown that landed me in the Critical Care Unit and then transferred to the psych ward for several weeks, was precipitated directly by my inability to sleep. The meds I was on at the time had gradually been causing more and more sleep issues, but they were actually working for depression and anxiety, so I didn't want to switch. Eventually, I was up all night, unable to sleep. On my lunch break, I would hide in an old storage closet at work and take a nap. Several days before I flipped for good, I hadn't slept at all. I'd tried every form of sleep medication and none of them worked. It sucked. Eventually, on the psych ward I got put on 100 mg of Seroquel to help me sleep, and I ended up falling out of bed the next day because I was so drugged and then got put on fall precautions.

The Seroquel worked for a while, but then left me feeling so drugged the next day it was almost as if I hadn't slept. Insomnia doesn't help anxiety or depression, and soon, I decided to switch SSRIs. Now I take my Prozac and a mildly sedating allergy medication and do, for the most part, okay.

And by okay, I mean back to my usual tossing and turning for an hour before I fall asleep. I did that in elementary school. I did that in middle school. I did that in high school. I would have done that in college, except I was so sleep deprived I often didn't even remember climbing into the top bunk. To my parents, this is completely and utterly baffling. How can you not sleep? Um, I don't know.

Last night was a fairly epic insomnia night, as I didn't fall asleep until 4am and then woke up at 7:30. I was definitely tired. That wasn't the problem. The problem was that my idiot brain would not stop yammering. It's like being seated next to a chatty old lady on a really long plane ride, and this old lady doesn't know how to shut up. She wants to tell you about her grandkids. And then show you the vacation photos. And then tell you about a fantastic hemorrhoid treatment. And don't--trust me, don't--get her started on her lovely Pomeranians. Meanwhile, in the seat next to the old lady, you're exhausted and you want to take a nap, but your headphones are in the overhead compartment, the decoy trashy romance novel isn't working, and there's no other seats on the flight.

That's what it's like for me to try and sleep. I close my eyes. I feel the heaviness and exhaustion wash over me, but there's this little old lady yapping in the back of my skull about her stupid Pomeranians. All I want to do is tell her to shut up about her freaking Pomeranians!! But she's 80 and the plane's crowded and you don't want to look like a jerk, so you basically pretend that she's some sort of rabid animal, and you hunker down, play dead, and hope she shuts up. She shuts up, you get some shut eye.

I've tried yelling at the motormouth in my head. Once I imagined myself turning around and yelling "WOULD YOU SHUT THE HELL UP!" The silence was deafening- I thought my brainpan was going to implode from the lack of chatter. That trick hasn't worked since.

It's not uncommon for me to be worrying, but even when I'm not worrying exactly, it's random useless chatter about Pomeranians and grandkids and hemorrhoid cream. And I don't know what else to do about it. Part of the issue probably has to do with the fact that I'm an extreme night owl and my brain just doesn't start to shut off until at least 1am, which is one of the major check boxes in favor of my decision to be a full-time freelance writer. I would love to get my sleep/wake cycle back to something resembling normal, but I am at a complete loss.

Thoughts or suggestions? I've done the no caffeine after 3pm, the relaxing music, the counting sheep, the tense your muscles and relax them, the meditation, the deep breathing, and nothing flips that stupid switch in my brain to off.

For anyone who has ever blogged, or has ever read a blog, this link is for you!

How to blog

I'm laughing hysterically right now.

An article I read about this past weekend's National Women's Figure Skating Championship was heartbreaking. It had nothing to do with the sport itself, or with the young lady's actual performance. For that matter, I don't usually watch figure skating anymore as it sets the ED voice in my head yammering about how slender and graceful all of those girls are, whereas I am neither slim nor graceful. Rather, when I read about the extreme perfectionism that has ensnared Olympic hopeful Mirai Nagasu, I felt my heart break just a little bit because I know all too well the hollow achievements such perfectionism can bring and the devastation it leads behind.

The New York Times article, "Nagasu Is in the Lead, but She Isn’t Ready to Exhale," begins thusly:

The good Mirai Nagasu, the one that oozes talent and effervescence, skated at United States championships on Thursday. She cracked a saucy smile and used her eyes to flirt with the crowd. With an Olympic berth at stake and the pressure mounting, she looked like she was having fun.

But now, with one performance standing between her and the Vancouver Games, she must find a way to keep the good Mirai around. That requires telling her alter ego, the one she calls “the evil Mirai,” to scram.

The "evil Mirai" is the silent voice that every perfectionist hears, the voice that hisses "you're not good enough. You suck. You should just quit. You will never amount to anything." It's the voice that makes you think success was a matter of luck, and soon the whole world will find out you're nothing but a fraud. Anything less than perfect--and pretty much everything is--only confirms all of the horrible qualities about you that no amount of gold medals can redeem.

For Nagasu, these nationals will be the ultimate test of character. She won the 2008 national title when she was 14. Since then, she has struggled with injuries, self-esteem and a growth spurt that messed up her jumping technique.

At one point, she considered giving up.

“There are always moments when I think about leaving skating, but when I think about that I’m not very smart and I’m not very pretty and there’s nothing else that stands out about me besides my skating,” she said.

Many times I contemplated dropping out of school, simply because I was so miserable, but I thought school was the only thing I was really good at, so I couldn't quit. I was stuck. Then the eating disorder took over the same role. Sure, recovery sounded nice, but I had messed up everything else in my life that I didn't think I was anything without the anorexia.

Writes author Rachel Simmons on Nagasu:

Nagasu is one of countless high achieving girls who are as fragile as they are driven. Research is confirming that girls suffer disproportionately from stress, despite their stellar achievements. The pressure to be perfect is taking its toll on girls, from depression and anxiety to paper thin skin.

I am reminded of part of Nancy Zucker's talk from this past year's NEDA Conference in Minneapolis, where she explains perfectionism in the story of two people working towards Olympic gold. One is very driven, always forging ahead, always practicing and improving her technique. Everything in her life is about getting this medal. The other is practicing, but also meeting new people and coaches, and learning from her mistakes. To this athlete, the gold medal is more about the journey than the actual event. “When the first girl gets the medal, she experiences the tragedy of perfectionism in this deflation: now what? My whole life was this, now it’s over," Zucker said. "When the other girl gets the gold, the gold is a symbol of a profound journey. It matters, of course, but it’s kind of: what next? The difference is not that there’s always something next, it’s the difference of whether you view what’s next with this hopelessness or this anticipation.”

Simmons refers to this first hypothetical Olympian as having a fixed mindset, "an approach to life in which you believe your traits are set in stone, and failure means you’re not talented or smart. For these individuals, “one test – or one evaluation – can measure you forever.” People with a fixed mindset are terrible at estimating their abilities because for them, they are either amazing or terrible – all-or nothing."

Without grades and exams, I never would have known that I was "good" at school. I was studious, sure, and I was good at getting the work done and crossing my "t"s and dotting my "i"s. But tell me I was smart? It always perplexed me, because I knew other people who had gotten better grades on such-and-such test or paper. One bad grade and my life was over. Even in my science writing program, where grades were pass/fail, I had horrific test anxiety. I didn't do stellar on the midterm, so I studied everyday before the final to make sure that I didn't repeat my last performance. I was so anxious and upset I could barely eat. I got an A in the class, yes, although it shows up on my transcript as a simple "P," a "P" that no employer or editor has looked at or even asked to.

I remember telling one of my first therapists that I thought I was a Big Dumb Loser, or something to that effect, shortly after I had graduated college and couldn't find a job. And she said, "How can you think that? Look at your resume!" Which only served to make me feel worse, because now I was a complete and total idiot for not recognizing whatever qualities it was that others could see and I couldn't. I wrote my resume out, thank you very much. I know what's on there. And I think of the people who won more awards, who did more advanced research, who published more papers, and I think my resume is utter crap.

It was the same with the eating disorder. Grades and test scores became calories and pounds. I couldn't have anorexia because there were people who weighed less than I did, people who ate less, people who exercised more. There was the thinnest, and there was everyone else. There was the smartest, and there was everyone else. My mom used to tell me, "Only one person can be the best." My response was always, "So why can't it be me?" I wasn't narcissistic--far from it. But I thought if I could ever be "The Best" at something, then I might finally like myself, then I could relax. So it was with school, so it was with anorexia.

These traits that Nagasu so bravely and candidly reports are traits I have seen over and over again in people with eating disorders and others who struggle with perfectionism. And hearing about all of these wonderful, talented people who think that they are scum never fails to break my heart. Yet my own inner critic rages on, telling me that these others are talented and I'm just One Big Fake. I feel I deserve this critic, feel almost lost without it. If my perfectionism was part of the reason that I've achieved what I have, imagine how much I'll suck if I don't have that constant haranguing in my ears.

And therein lays the problem: I'm afraid that breaking free will only confirm my worst fears, so here I stay, checking the spelling again and reading everything over and hoping one day, I will finally measure up.

Your weekly assortment of unusual nibbles from around the web and various research journals. This week's selections were unusually eclectic, so I hope you enjoy!

TEDMED

I've blogged before about the TED Talks, and this fall, there is going to be a second TEDMED, a four-day series of TED talks on all aspects of health and well-being. I've never listened to a TED talk and not been at least marginally intrigued, so I'm especially keen to listen to these talks. The 2009 speakers are currently up, although the 2010 speakers haven't been announced yet. One of my life fantasies is being asked to do a TED Talk and you, my dear readers, would be the first to know if I ever got asked (hint, hint...Universe...are you listening?).

Strep today, anxiety tomorrow?

It sounds almost sci-fi in its wackiness- a common bacteria can trigger a serious mental illness. Yet over the years, evidence has been growing that a particular subset of pediatric Obsessive-Compulsive Disorder (OCD) patients may have had their illness triggered by an infection with Streptococcus. Known as PANDAS (pediatric autoimmune neuropsychiatric disorders associated with strep), the diagnosis is still rather controversial, although one PANDAS researcher estimates that approximately 25% of all pediatric OCD and Tourette's syndrome patients may in fact have PANDAS. Scientific American Mind does a good job of introducing the subject:

In the 1980s Susan Swedo, a pediatrician at the National Institute of Mental Health, came across several cases of children who seemed to have developed tics and behaviors resembling OCD, such as excessive hand washing, overnight. Swedo noticed that the children in all the cases had recently recovered from strep throat. The traditional strep symptoms were gone, but when she did laboratory tests, Swedo found the children’s blood still contained high levels of strep antibodies. Perhaps most compelling, the symptoms seemed to abate after renewed treatment with antibiotics. Swedo became convinced that the symptoms were the result of an overactive immune response to strep bacteria.

These strep bacteria have long been known to trigger auto-immune conditions, such as rheumatic fever. Evolution and natural selection have given the bacterial antigens similar shapes to human antigens to confuse the immune system (the body is supposed to destroy any of its antibodies that react to "self" antigens). But this doesn't always work 100%, and the same antibodies that help the body fight off strep infection can then attack the body itself. In rheumatic fever, the body's immune system attacks the heart. In PANDAS, the immune system is thought to attack the basal ganglia, which leads to the abrupt development of OCD symptoms and tics.

Cognitive Behavioral Therapy is still the treatment of choice for OCD, but people with suspected PANDAS also show a reduction of symptoms with a low dose of penicillin. A recent study in mice appeared to replicate the strep antibody response seen in human that is thought to cause PANDAS, which may lead to a better understanding of what causes PANDAS and how to best treat it.

Interestingly, PANDAS has also been tentatively (very tentatively, I might add) associated with anorexia, especially in younger children. There have been very few research papers published on the subject (a PubMed search of "PANDAS anorexia" only turned up three), and it's been known to make some clinicians and researchers twitch a little bit. To be sure, the evidence isn't great, but I also think we would be doing everyone a disservice by not looking into it.

Startle as an objective measure of distress related to teasing and body image

Though not exactly rocket science (people who were teased about their appearance had a more negative reaction to pictures of themselves morphed to look heavier), this study, published ahead of print in the International Journal of Eating Disorders, did have some interesting results.

From the abstract:

All participants, regardless of teasing history, self-reported that the photo morphed to look heaviest was more unpleasant than the neutral photo. When assessed by the affect modulated startle paradigm, a significant teasing history by photo interaction was found between the neutral and morphed to look heaviest photos and the neutral and morphed to look smallest photo. Those with a teasing history had greater startle response to the morphed images in comparison to the neutral images than did those without a teasing history. College-aged women with weight-related teasing histories may have negative emotional reactions to personally relevant body image cues, as measured by the startle reflex, even when they subjectively report no distress. Objective measures, such as the startle reflex should be considered when assessing emotional reactions to body image cues.

Assessing startle reflex could be an interesting and innovative way to try and measure people's body image on a visual, rather than verbal, level. I'd be curious to see what my results were, since I, too, have a history of being teased about my weight.

The surprising reason why being overweight isn't healthy

CNN had a fantastic article earlier this week about the real reason fat may be so (seemingly) unhealthy. It's not ZOMG TEH FATZ! but rather discrimination against people who are fat. Thus says CNN:

A recent Yale study suggested that weight bias can start when a woman is as little as 13 pounds over her highest healthy weight. "Our culture has enormous negativity toward overweight people, and doctors aren't immune," says Harvard Medical School professor Dr. Jerome Groopman, M.D., author of "How Doctors Think." "If doctors have negative feelings toward patients, they're more dismissive, they're less patient, and it can cloud their judgment, making them prone to diagnostic errors."

The story describes a larger women who went to the doctor's office with an asthma flare-up. Instead of discussing her breathing, she got a lecture on her weight. Because we all know how easy it is to exercise when you can't freaking breathe. Hypoxic exercise...blue is the new black, right?

Seelaus's nurse made a classic diagnostic error, according to Groopman. "It's called attribution, because your thinking is colored by a stereotype and you attribute the entire clinical picture to that stereo­type. Because obesity can cause so many health problems, it's very easy to blame a variety of complaints, from knee pain to breathing troubles, on a patient's weight. That's why doctors -- and patients -- need to constantly ask, 'What else could this be?' "

There aren't statistics on how many diagnostic errors are due to weight, but the data for the general population is disturbing enough. "Doctors make mistakes in diagnosing 10 to 15 percent of all patients, and in half of those cases it causes real harm," Groopman says. Based on anecdotal evidence -- patients who've told her that their doctors are often too quick to blame symptoms on weight -- Rebecca Puhl, Ph.D., director of Research and Weight Stigma Initiatives at the Rudd Center for Food Policy and Obesity at Yale University, suspects that being heavy could further increase the odds of being misdiagnosed.

Of course, the article did have some smashingly ignorant quotes, such as "Whether they know it or not, doctors' attitudes may actually encourage unhealthy behavior. Feeling dissed about their weight can make some women turn to food for comfort. "Stigma is a form of stress, and many obese women cope by eating or refusing to diet," Puhl says. "So weight bias could actually fuel obesity." "

Except for the teensy little fact that DIETS DON'T WORK. Also, since when is discrimination against fat people surprising? It's been around for quite some time, and anyone who is even a few pounds heavier than what our culture deems acceptable knows damn well the differences in how people get treated.

Still, it brought attention to the issue, which is the first step. Just do NOT, for any reason, read the comments. They will make you crazy.

Thus concludes this week's smorgasbord. Join me next week for some new findings!

One of my recovery friends on Twitter this week had this to say:

"It is more & more evident that to recover from an ED is to overcome core neurological, psychological, personality traits."

And I had to agree. Another one of my recovery friends, Finding Melissa, sagely questioned whether one could really overcome such core traits. Rather, said Melissa, the task is to learn to live with them. My therapist put it slightly more informally: I have to learn how to use my traits for good instead of evil. Fighting a war with yourself dooms you to lose, in some way, shape, or form.

And that's really what the hardest part of recovery is--not the eating and the weight gain, but the task of Know Thyself. Know your own personal triggers. Know your vulnerabilities. Know your weak spots. Know who you can turn to in a crisis, or before a crisis. Know the signs of relapse. Know the signs before the signs.

My recovery from anorexia has changed me profoundly- I'm not the same person now that I was before, nor would I want to be. Although I have changed in very profound ways, I still have the same personality and temperament. I am still frequently anxious and irritable (irritability, I've come to learn, is always a sign of anxiety), I am still perfectionistic, I still have many instances of black or white thinking and other cognitive distortions. These are not likely to change, even with therapy. A therapist once asked me, "Did you always have a need for control?" The truth is, yes, I did. The truth is, I still do.

So maybe I won't ever completely overcome my inborn personality traits, and that's okay. But the work of trying to live with them in peace and (relative) harmony is exhausting. It's grueling, excruciating work. And I don't know anyone who is in recovery or who has recovered that hasn't done it. Recovery changes us, but we're still the same people.

Earlier this week on Twitter (do you follow ED Bites on Twitter? You know you want to...), I ran across an interesting article about why some antidepressants don't work in some patients. The article was published last week in the research journal Neuron and is titled "5-HT1A Autoreceptor Levels Determine Vulnerability to Stress and Response to Antidepressants." (Clicking the link will take you to the free full-text of the article.) I'll let the opening of the article's Science Daily press release explain the research for me:

An excess of one type of serotonin receptor in the center of the brain may explain why antidepressants fail to relieve symptoms of depression for 50 percent of patients, a new study from researchers at Columbia University Medical Center shows.

...Most antidepressants -- including the popular SSRIs -- work by increasing the amount of serotonin made by cells -- called raphe neurons -- deep in the middle of the brain. Serotonin relieves symptoms of depression when it is shipped to other brain regions.

But too many serotonin receptors of the 1A type on the raphe neurons sets up a negative feedback loop that reduces the production of serotonin, Dr. Hen and his colleagues discovered. "The more antidepressants try to increase serotonin production, the less serotonin the neurons actually produce, and behavior in mice does not change," Dr. Hen says.

Seeing as anti-depressant therapy hasn't shown much promise in the treatment of anorexia nervosa (although it does appear to help treat co-morbid conditions like depression and anxiety), this research could help with the development of new treatments for AN. It also seemed like a good a time as any to discuss the links between serotonin levels and eating disorders. In a 2005 review article, titled "Serotonin alterations in anorexia and bulimia nervosa," Walter Kaye wrote that people with either anorexia and/or bulimia showed alterations of brain functioning in specific neural areas:

Importantly, such disturbances are present when subjects are ill and persist after recovery, suggesting that these may be traits that are independent of the state of the illness. Emerging data point to a dysregulation of serotonin pathways in cortical and limbic structures that may be related to anxiety, behavioral inhibition, and body image distortions...Alterations of these circuits may affect mood and impulse control as well as the motivating and hedonic aspects of feeding behavior. Such imaging studies may offer insights into new pharmacology and psychotherapy approaches.

The serotonin/anorexia connection has been researched over the years (searching PubMed for "serotonin anorexia" gives you over 700 results), and the most recent thinking goes something like this. People with anorexia are generally thought to have unusually high levels of serotonin in their brains, and high levels of brain serotonin have been linked to anxiety and obsessionality. An old BBC article titled "Genetic clues to eating disorders" has a quote from Janet Treasure that explains some of the link:

People with high levels of serotonin are prone to anxiety. Dr Janet Treasure, director of the eating disorders unit at the Maudsley, believes this could be behind anorexic patients' ability to suppress appetite. She said: "In anorexia nervosa the drive to eat can be inhibited, but we know that in normal people who are starved they will kill each other and do all sorts of morally repugnant things, and eat all sorts of foodstuffs that you wouldn't normally touch.

"Yet that doesn't happen in anorexia nervosa, so there's some aspect of the appetite system that isn't working."

The unit looked at the biology of stress mechanisms, in particular the fight or flight response. This is where the body prepares itself for action when confronted by a stressful situation. Heart rate and blood pressure rise and two of what are usually humans' highest priorities, eating and reproducing, are put on hold. It is possible that anorexic people are chronically in an acute state of stress reaction - they are constantly in a fight or flight state of mind.

And by restricting food intake, people with anorexia can lower the amount of serotonin their bodies can make (serotonin is ultimately derived from the essential amino acid tryptophan). This actually makes people with anorexia feel better. However, the brain begins to sense the decreased serotonin production and tries to maintain homeostasis by increasing the number of serotonin receptors. Thus the brain is back at Square One, as it is producing less serotonin but is using the decreased amount much more efficiently. So restricting doesn't feel as good, and the (obvious!) solution is to eat even less. And thus that negative cycle is born and the anorexic becomes trapped by their own brain chemistry.

Refeeding would then increase the amount of serotonin in the brain before the brain has a chance to decrease the number of serotonin receptors. This could be the neurological equivalent of All Hell Breaking Loose and could very well explain why refeeding is so distressing, although I don't think there has been any formal research done on the subject.

In bulimia, the serotonin problem is reversed. People with BN appear to have much lower than average levels of serotonin in the brain, which may be temporarily increased by binge eating.* Purging increases levels of vasopressin, which can have a euphoric and sedating effect, thus making the binge/purge cycle addictive much in the same way that starvation becomes addictive in AN. The chronic low levels of serotonin in BN also explain why SSRIs can be effective at reducing the urges to binge and purge.

Of course, plenty of people cross over from anorexia to bulimia, and I haven't the slightest idea of how serotonin might affect that crossover. So many brain systems are thrown out of whack during an ED that I don't know an exact answer will ever be found.

*The story is, as usual, a little more complicated than this, but the basic idea is the same.

The news of my Salzburg Scholarship yesterday got me thinking about how my eating disorder has impacted my life. I never thought when I first got sick that this journey would last so long and result in so many changes in my life--like getting a scholarship to attend an international eating disorders conference.

Shortly after I was first diagnosed and began actually acknowledging that I had a "problem," I thought that my initial decision to lose five pounds was probably the worst I had ever made. Certainly, it was a doozy. But along with that thinking went the idea that if I just went to enough therapy, I could put this whole "problem" behind me and my life would go on as if nothing ever happened.

Time passed and this "problem" dragged on, but I still thought that I could put everything behind me. And as time continued to pass, I began to grow bitter about the fact that an increasing number of years of my life were being sucked up by this stupid eating disorder. I thought I should have been smarter than to get entangled with anorexia. I thought I wasn't working hard enough in therapy. I started to wonder why on earth I had been cursed with an illness that made me afraid to eat.

I still don't know exactly why I got sick. I know genetics had a lot to do with it. I know that it wasn't a misalignment of the planets, or a divine punishment, or a foregone conclusion (Girl in Modern American Succumbs to Pressure To Be Thin! OMG- STOP THE PRESSES!). But that still didn't stop me from being bitter about the whole experience. I wanted to erase anorexia from my life, get past it and never speak of it again and one day, it would be like a very bad dream, only with bone density scans every two years. I was truly and profoundly pissed off. Anorexia and hospitalizations and treatment and beeping heart monitors and near-death experiences was not in my plans. This was not how things were supposed to go. I was supposed to graduate from college, get a fellowship to become a PhD virologist and then I would work at the Centers for Disease Control while fighting Virus X amongst the rural poor of some famine-stricken African country.

I had it all planned out.

And then came the decision to exercise a little more, eat a little less, and shave off the five pounds I'd gained while studying abroad in Scotland, and all of my plans literally went down the toilet.

So yeah, I was seriously pissed.

I recanted a little bit- first I would get my Master's in Public Health, and then my PhD in Infectious Disease Epidemiology, and then I would go work for the CDC and fight Virus X. Except ED followed me to grad school (persistent little bastard) and I managed to get my MPH but had no energy or fight to pursue any more education. I was done.

ED then followed me into the job world (like I said, he's a persistent little bastard), and that's when I realized my life plans had been well and truly f*cked. There was no getting around this eating disorder. I thought I could stay slightly underweight and get on with things, but I'll let you guess how that little idea turned out. As my brain begins to wrap itself around the knowledge that my life has been utterly scrambled, the anger then starts to seethe. I was angry that therapists didn't whack me over the head with their magic wands. I was angry I hadn't gotten sicker and lost more weight, because if my life was going to pot, at least I could have done something decently. I got angry that many of my friends had managed to recover with minimal outside help, and here I was, still stuck and treatment bills still mounting. It wasn't fair.

No. It wasn't.

Yet it was because of the eating disorder that I first seriously began to write. It was because of the eating disorder, and the desperation with which I was seized, that I screwed up the courage to apply to a science writing program. It was because of the eating disorder that I quit my dreary corporate-esque job to heal and then begin freelance work full-time.

I'm not happy I got sick. It doesn't make me proud, and I still cringe when people ask me about my college years. For that matter, I probably always will. But--and this is perhaps where my thinking has shifted the most over the past few months--I would no longer just wipe those years from my life. If I wanted to be all happy and mushy and positive, I would call them "Learning Experiences," and wax poetic about how strong I learned I could be. But you know me better than that. This past decade was what it was. Yes, I had anorexia. Yes, it sucked. Yes, it totally screwed with the life plans I'd had since seventh grade when I made my first Punnett Square. Would I have been happy as a scientist? Quite possibly. Would I have ever discovered my real love of writing if I hadn't gotten sick? I don't know. I'm not happy I got sick. I'm never going to sling my arm around Anorexia's shoulder and say "Gee, I'm so happy we had this chance to get to know each other."

If I could stand in the shoes of 20-year-old Carrie and make that decision again about whether or not to start eating more healthfully, I would tell her not to do it. But I no longer harbor an immense resentment towards my younger self for getting sucked into anorexia and having such a difficult time finding her way out. It is what it is. My experience of an eating disorder and recovering from it have profoundly changed me. I'd have to erase over one-third of my life, and I'm not so sure I'm willing to do that.

...with the sound of the 2010 Academy for Eating Disorders Conference in Salzburg, Austria. Need an excuse to go? I'll be there!

I just received word that I got a Patient/Carer Scholarship to help defray some of the costs of attending the conference. The other scholarship recipient was none other than my fabulous friend June Alexander.

Need another reason to go? Laura Collins will be presenting!

I've never been to Europe before, despite spending almost 6 months at the University of Aberdeen in Scotland (I skipped the seemingly obligatory weekend in Amsterdam to legally smoke pot because I had a paper due. I'm not harm avoidant and perfectionistic, not at all). So I am super excited not only for the conference, but also to hopefully travel around Europe a bit while ED can drown in the Atlantic.

Sleep now beckons, so I will apologize for the slightly spastic, disconnected post (I can haz grammar?) and check in with a regular post tomorrow.

Two studies were published this week that made the connection between genetic variations and anxiety disorders in both humans and animals.

One study, published in the journal Science, found that mice and humans with the same mutation in an anxiety-related gene behave similarly. The study, titled "A Genetic Variant BDNF Polymorphism Alters Extinction Learning in Both Mouse and Human," sounds almost deliberately obtuse, but the results are interesting. Lab rats (or in this case, lab mice) are often used in research for any number of reasons, which include the fact that they are small and relatively easy to handle, they reproduce quickly, and over a century of intense breeding and research has enabled researchers to know an animal's exact genetic profile. Many studies in behavioral neuroscience use mice and rats for these reasons, and also because it's generally difficult to get humans to participate in many of these experiments (which are often ended by autopsy so the brain can be examined). From a genetic standpoint, there aren't a whole lot of differences between a human and a mouse. Many of the tasks we both have to complete--digesting food, eliminating waste, maintaining homeostasis--are pretty darn similar, so researchers have hypothesized that the neural circuits controlling behavior in mice and people are actually similar.

This most recent study looked at a variation in the gene that makes Brain Derived Neurotropic Factor (BDNF), a protein responsible for brain growth and development. The interesting result was that the mice and humans who had this variation had similar behaviors. From a Science Daily press release:

To make their comparison, the researchers paired a harmless stimulus with an aversive one, which elicits an anxious-like response, known as conditioned fear. Following fear learning, exposure to numerous presentations of the harmless stimulus alone, in the absence of the aversive stimulus, normally leads to subjects extinguishing this fear response. That is, a subject should eventually stop having an anxious response towards the harmless stimulus.

"But both the mice and humans found to have the alternation in the BDNF gene took significantly longer to 'get over' the innocuous stimuli and stop having a conditioned fear response," explains Dr. Fatima Soliman...

...[Researchers] found that a circuit in the brain involving the frontal cortex and amygdala -- responsible for learning about cues that signal safety and danger -- was altered in people with the abnormality, when compared with control participants who did not have the abnormality.

"Testing for this gene may one day help doctors make more informed decisions for treatment of anxiety disorders," explains Dr. Francis S. Lee.

Specifically, it may help therapists tailor approaches to treating anxiety such as exposure therapy, which is an empirically supported treatment for a variety of anxiety disorders, such as phobias and PTSD.

"Exposure therapy may still work for patients with this gene abnormality, but a positive test for the BDNF genetic variant may let doctors know that exposure therapy may take longer, and that the use of newer drugs may be necessary to accelerate extinction learning," explains Dr. Soliman.

BDNF has also been associated with both anorexia nervosa and bulimia nervosa.

In a completely separate study, researchers have identified a genetic mutation that results in compulsive behaviors in a wide variety of animals. From a New York Times article on the study:

Researchers studied Doberman pinschers that curled up into balls, sucking their flanks for hours at a time, and found that the afflicted dogs shared a gene...the findings [have] broad implications for compulsive disorders in people and animals.

Dr. Dodman and his collaborators searched for a genetic source for this behavior by scanning and comparing the genomes of 94 Doberman pinschers that sucked their flanks, sucked on blankets or engaged in both behaviors with those of 73 Dobermans that did neither. They also studied the pedigrees of all the dogs for complex patterns of inheritance. The researchers identified a spot on canine chromosome 7 that contains the gene CDH2 (Cadherin 2), which showed variation in the genetic code when the sucking and nonsucking dogs were compared.

The statistical association led to further investigation to determine for which protein the gene contained instructions. It did for one of the proteins called cadherins, which are found throughout the animal kingdom and are apparently involved in cell alignment, adhesion and signaling.

Cadherins have also been recently associated with autism spectrum disorder, which includes repetitive and compulsive behaviors...

...“Stress and anxiety, as well as physical trauma and illness, can trigger repetitive behavior that then takes on a life of its own,” Dr. Ginns said.

But he believes that in many cases there is an underlying genetic predisposition that responds to environmental stimuli in such a way that once-normal behavior turns into something pathological. Those genetic dispositions may differ markedly between different behaviors.

Considering the links recently postulated between anorexia and autism as well as anorexia and OCD, these results may one day have an effect on our understanding of eating disorders.

Prostate cancer survivor Dana Jennings opens his fantastic NY Times essay as follows:

Still haunted and chastened by the Puritan work ethic, our culture doesn’t much believe in convalescing, in full recovery. No matter what happens in our lives — a grave illness, a wrenching divorce, a death in the family — the unspoken understanding is that we should want to rush back into the game. Like an old-time quarterback who has had one concussion too many, we are expected to stagger back onto the field no matter what.

These words got to the heart of what I am feeling right now, which is a tremendous guilt at being physically okay but still not "whole." I still get fatigued rather easily. I still get overwhelmed by the littlest things. I still cannot fathom exactly how to go about eating three meals and 2-3 snacks every day, of deciding what to have, preparing it, and cleaning up afterwards. I still have days when I want to ask "Remind me again why I'm doing this?"

And then I snuggle with my kitty and I remember, for a while at least.

It's hard for outsiders to understand just how much fighting a life-threatening illness can take out of you. It often seems that the world is out there, tapping its foot, and impatiently demanding "Aren't you better yet?"

No. No, I'm not.

Maybe I need to think of this time of decreased demands as a kind-of Gift From The Universe. I'm lucky to be able to get by on the occasional freelance writing job thrown my way, to not have to worry about the intricacies of food prep and bill paying. In the end, Jennings says it best:

Recuperation is just physical. The claw of the surgical incision relaxes its grip on your gut. You graduate from catheter to man-diapers to man-pads to, finally, your very own comfy boxers. Energy seeps back into your body after the radiation and the hormone therapy cease.

But recovery means wholeness: mind, body and spirit. And I reached a point last summer and fall when I realized that even though I was back at work, once again juking and stutter-stepping my way through the streets of Manhattan, I hadn’t recovered at all.

I thought I had weathered the trauma of diagnosis and treatment, thought I was ready to focus on the future. But my body disagreed.

Physically, I was game, but I soon realized I was going through the motions as I became more and more tired. I felt like a spinning quarter about to nod to gravity and wobble to the tabletop. Mentally, I couldn’t focus: I became shawled in the monochromes of depression. And spiritually, I wasn’t angry — I did want to know what this cancer could teach me — but just right then I couldn’t make sense of my cancer-blasted interior landscape.

...After surgery and treatment, my 21st-century synapses and neurons wanted to believe that the cancer had been no more than a bump in the road toward a bright future — just a particularly nasty frost heave.

But the deepest analog part of me understood that having cancer was a life-changing event. As much as I thought I wanted to forge ahead, surge into the whirlwind of dailiness, I needed to slow way down.

The scar on my gut might have faded a bit — I had indeed recuperated — but I still needed to recover.

The New York Times had a wonderful article by Abby Ellin, author of "Teenage Waistland: A Former Fat Kid Weighs In on Living Large, Losing Weight and How Parents Can (and Can’t) Help," called Narrowing an Eating Disorder, which looked at the troublesome diagnosis of EDNOS and what should and could change for the DSM-V.

Writes Ellin:

To maintain some semblance of control, I divided my eating into Food Days and Nonfood Days: that is, days when I consumed vast amounts, and days when I policed my caloric intake with military precision. The routine kept my weight in check, more or less. Never mind that it was insane.

No one at my college health center knew what to do with me. Clearly, I wasn’t anorexic; I was slightly round, in fact. I didn’t purge, so bulimia was out. To my distress, the counselors told me there was nothing they could do for me and sent me on my way.

Today, I would probably qualify for a diagnosis of “eating disorder not otherwise specified,” usually known by its acronym, Ednos.

The majority of eating disorder diagnoses are, in fact, EDNOS. I'm not saying that the EDNOS category isn't useful (it can capture emerging trends in ED behaviors that might not fit into any other specified categories rather than just ignoring them), but if "not otherwise specified" is the most common diagnosis, it's a sign that we don't do a good job of defining what eating disorders exist out there. In a major study on the severity of EDNOS (Fairburn et al 2007), researchers found that:

These cases closely resembled the cases of bulimia nervosa in the nature, duration and severity of their psychopathology. Few could be reclassified as cases of anorexia nervosa or bulimia nervosa. The findings indicate that eating disorder NOS is common, severe and persistent. Most cases are "mixed" in character and not subthreshold forms of anorexia nervosa or bulimia nervosa. It is proposed that in DSM-V the clinical state (or states) currently embraced by the diagnosis eating disorder NOS be reclassified as one or more specific forms of eating disorder.

Fairburn in particular is known for his thinking on the "transdiagnostic model of eating disorders," which he explores in depth in a paper titled "Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment." Fairburn believes that the varying clinical symptoms and psychopathology of eating disorders are maintained by similar processes (clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties), that distinguishing between different ED diagnoses is the psychiatric equivalent of hair-splitting. Simply speaking, eating disorders have far more similarities than they do differences. Whether or not you entirely agree with Fairburn (I'm not entirely convinced myself), he does have some very good points.

With the upcoming DSM-V revision, clinicians and researchers have been looking at potential changes to the ED diagnostic criteria. A recent full-text article in the International Journal of Eating Disorders titled "Broad categories for the diagnosis of eating disorders" received great coverage over at Psychotherapy Brown Bag, and rather than reinvent the wheel, I will leave you to their wonderful shake-down of the evidence and its implications.

Dr. Tim Walsh at Columbia University had a great quote on the issues with the "EDNOS" diagnosis as it is currently used:

“The consensus is that Ednos is ‘too big,’ meaning it is being used more frequently than is desirable, as that label does not convey much specific information,” said Dr. B. Timothy Walsh, a professor of psychiatry at Columbia who is chairman of the eating disorders work group for the new manual.

Then there are the intricacies of the psychology so unique to eating disorders that also presents problems with the EDNOS diagnosis:

“A lot of patients feel this stigma if they know they’re diagnosed with Ednos: ‘Obviously, I’m not good enough to be anorexic,’ ” said Nicole Hawkins, director of clinical services at Center for Change, an eating disorder treatment center in Orem, Utah. “I’ve had many patients feel that they need to lose more weight so they lose their period so they can change the diagnosis. Patients really feel they have to get ‘better’ at their eating disorder to deserve treatment.”

Perhaps the most erudite comment in the whole article that completely exemplifies what is wrong with the DSM in general and EDNOS in particular is from Dr. Craig Johnson of the Laureate Eating Disorders Clinic.

“What Ednos really demonstrates,” said Dr. Johnson, at Laureate in Tulsa, “is that we don’t have empirically derived diagnoses in psychiatry."

I don't generally read the comments to articles like this, but there was one comment from the Well blog post on this article that completely exemplifies our culture's messed-up relationship to eating disorders:

Could someone please explain which alternating Food/Non days is a disorder. If it helps one manage food, sounds just fine with me. It ain’t gonna kill the patient!!!

Except that it very well might.

For more reading on the DSM-V and eating disorders, check out these full-text articles from the International Journal of Eating Disorders.

Yet another installment of some interesting nibbles related to eating disorders. I hope you enjoy this week's selection!

Our Basic Human Pleasures: Food, Sex, and Giving

Finding happiness is something that I think everyone struggles with. I used to think that losing weight would make my happy--or at least happier because I wouldn't have to be anxious about what I weighed. Obviously, this didn't work. I think lots of people try to find happiness, and there are many blogs and books that address the topic, and the answer is relatively simple: our social networks have a lot to do with how happy we are. Humans need other people.

What attracted me to this Nicholas Kristof op-ed piece in the New York Times was the fact that the title discussed how food and sex were among some of the basic human pleasures. An eating disorder pretty much obliterates the possibility of enjoying the first two (the food part is obvious, the sex part tends to be secondary to malnutrition), so I was curious to see what Kristof had to say. It turns out the article was about how altruism may be as basic of a pleasure for humans as food or sex.

"So at a time of vast needs, from Haiti to our own cities, here’s a nice opportunity for symbiosis: so many afflicted people, and so much benefit to us if we try to help them. Let’s remember that while charity has a mixed record helping others, it has an almost perfect record of helping ourselves. Helping others may be as primal a human pleasure as food or sex."

In times of great need, it's important to honor both our basic human needs for food and water, and also to help others.

Accept Defeat: The Neuroscience of Screwing Up

Perfectionism is one of the major traits of people with eating disorders. I'm, like, the Perfectionism Poster Girl (although many times I don't think I'm good enough to be a Perfectionism Poster Girl, which probably indicates why I should be the Perfectionism Poster Girl). It turns out, however, that our mistakes and failures can teach us more than any successes.

The reason we’re so resistant to anomalous information — the real reason researchers automatically assume that every unexpected result is a stupid mistake — is rooted in the way the human brain works. Over the past few decades, psychologists have dismantled the myth of objectivity. The fact is, we carefully edit our reality, searching for evidence that confirms what we already believe. Although we pretend we’re empiricists — our views dictated by nothing but the facts — we’re actually blinkered, especially when it comes to information that contradicts our theories. The problem with science, then, isn’t that most experiments fail — it’s that most failures are ignored.

It's a hard lesson for a perfectionist like me to swallow: perhaps I shouldn't be striving to avoid failures, but rather striving to learn from them, to take in the information I might not want to hear. Rather than writing off the failure as obviously my fault (I'm still anxious about my weight...I know, let's lose more weight!) and look closer at the data at hand (Gee, I've only been more miserable since I've started losing weight...could this be the real problem?).

Failure is a part of life. So if that's the case, we may as well make the best of it.

Risk factors and ED Prevention

A recent study from Eric Stice at the Oregon Research Institute looked at risk factors for eating disorders and how they should inform our prevention efforts. The entire abstract is fairly straightforward, so I've copied and pasted it here:

Prospective studies have identified factors that increase risk for eating pathology onset, including perceived pressure for thinness, thin-ideal internalization, body dissatisfaction, dietary restraint, and negative affect. Research also suggests that body dissatisfaction and dietary restraint may constitute prodromal stages of the development of eating disorders. Prevention trials indicate that interventions that reduce pressure to be thin, thin-ideal internalization, body dissatisfaction, and negative affect significantly reduce eating disorder symptoms. Further, there is evidence that selective prevention programs that target young women at elevated risk for eating pathology by virtue of thin-ideal internalization, body dissatisfaction, and negative affect produce significant larger intervention effects than do universal programs offered to unselected populations. Thus, research on risk factors and prodromal stages of eating pathology has assisted in the design of efficacious prevention programs and the identification of high-risk individuals to target with these interventions; additional research in this area may lead to even more effective prevention programs.

I'm not going to say that Stice is wrong; however, I don't know that this is the whole picture of effective ED prevention. We know anxiety disorders are very common in people with eating disorders, so prevention efforts along those lines might be more effective at preventing EDs. We don't know. Yes, body image is an important aspect of eating disorders for many people (though not all!) and distorted body image is a problem in people who don't have clinical eating disorders. But that's not the only path to an ED, and I wish there was more recognition of this in prevention efforts.

Sleep disturbances in women with EDs

I've been an insomniac since I was a child, but the eating disorder was one of the big heydays of my insomnia. Researchers have long known that many people with eating disorders also have difficulty sleeping, but this study looked at sleep disturbances among different diagnoses and subtypes of EDs. They found that people with the binge/purge subtype of anorexia, and the purging subtype of bulimia had the most disturbed sleep patterns, and that an increase in sleep disturbances was correlated with a greater severity of binge eating and vomiting.

Thus we have almost come full circle back to the first piece in this smorgasbord: the importance of food and sleep in human happiness. They're so easy to neglect, but so important to remember.

I realize this post could easily get into the boo-hoo my life sucks realm rather quickly, so this is going to be a little disclaimer that I'm not wallowing in self-pity. It's more of what one of my Aussie friends would call a good little bitch 'n whinge.


I know that I've made plenty of progress in recovery over the past six months. I'm not trying to deny that. But considering that I'm in a fairly protected situation, it's easy for me to forget just how far I have to go. Swimming in a pool is different than swimming in an ocean with currents and riptides. I'm in a pool right now (metaphorically- the thought of wearing a bathing suit sends me into a panic), but the world out there is one big, big ocean. And every now and again, I realize that the pool and the ocean are very different places.

I was out with my parents all day yesterday, and I managed lunch just fine (which is progress, I know), but the afternoon snack was much more anxiety-provoking. I was in an unfamiliar area that had several places where we could stop. My mom asked "Would you like to stop for a snack?" and although I get that she was trying to be all nice and supportive, I really wanted to say "No, actually, I'd rather not stop for a snack!" But seeing as that wasn't an option, I started thinking of all of the different places where we could go. My mom encouraged me to pick something, and I just stood there, totally and utterly unable to decide what to do or where to go. My dad was getting impatient, as stopping for a snack wasn't on his agenda (we were shopping for furniture and only furniture, and snacktime and poking through the bins at Crate and Barrel were not Part Of The Plan), so he just hustled us along and I ended up eating some of the snacks we had packed for precisely just an emergency.

I talked to my therapist about this, and I can see that I was reasonably effective. I didn't skimp on my snack because I was anxious or couldn't decide. Again, progress. But what caught me off guard was how anxious that decision still made me. It wasn't the prospect of eating that made me all twitchy, it was having to decide what to eat. I have a meal plan, I have supervision, I haven't had any urges to binge or overeat, so I can be reasonably confident that I'm not going to drastically exceed what my body needs. Also, my hunger and fullness cues are in (reasonably) good working order, so it's really not the eating part that causes the crippling anxiety anymore. But the task of deciding what to eat? Holy cats. Massive anxiety.

Part of the anxiety comes from this internal dialogue of trying to decide whether ED is calling the shots or healthy Carrie is calling the shots. One of the upsides of anorexia--if you can call it that--was that I didn't have to ask myself what I wanted. Eating was a big part of that, obviously, because I was always full or had just eaten or [insert random reason here]. But as long as I could figure out which decision would help me lose weight, I could decide. Easily. I'm not used to asking myself what I want to eat, and having to decide is so hard. I do pick out and serve my own snacks at home, but there's a relatively limited array of options to choose from. No one is getting antsy for me to make up my mind so we can price out that sectional.

Besides the anxiety of figuring out what I want, there's the anxiety of wondering if I made the right decision. Because, as we all know, perfection is possible in an afternoon snack...right? The rational part of me understands that not ordering the perfect item at the perfect place is hardly a life and death matter. I could order something different next time and the world would not end. However, very little about an eating disorder is rational. I worry about potential calorie differences in the snacks at Place A and the snacks at Place B. I worry what other people might think of me if they see me walking around with something from Place A instead of Place B. I worry what people must think of me if they see me eating, period. I worry about cost. I worry about where other people might want to go. I worry about looking like a slack-jawed freak as I stand in the middle of the mall, not moving, as I try to decide between Place A and Place B, but then what about Place C just around the corner?

And on and on it goes.

I get that these worries are pretty darn irrational (okay, completely and utterly irrational), but they're still very real, and they're part of the reason why a simple question like "Do you want a snack?" can leave me frozen in my tracks. I can probably find something wherever I end up--which is one of the upsides to being given plates of food with relatively little input--however much I might not like the options. And if somebody says "Let's go to Place A," and I really want to go to Place B, I am feeling more free to suggest Place B unless the other person really wants to go to A and I don't have a huge preference for B. But if that somebody asked "Where do you want to eat?" or even "Do you want to eat at Place A or Place B?" it's like that anxiety immediately kicks in and I start second-guessing everything.

I guess we can add this to the never-ending list of Things I Need To Work On In Therapy.

"A soteria is the positive analogue of a phobia. A phobia is an irrational fear of some object, whereas a soteria is an irrational attraction to some other object. In popular US culture, the most famous soteria is Linus's blanket, but I bet that most of us have our own examples, even if we don't have a label for them."

So writes psychologist Christopher Peterson in his blog The Good Life. I've written before about how many aspects of an eating disorder seem like a phobia, but there are also many aspects of an eating disorder that seem like a soteria--albeit a sick, twisted, messed-up one.

Let me explain a bit. I've often thought of my eating disorder as my metaphorical security blanket. No matter how bad the world got, I could always cuddle up with my blankie and make everything okay. Instead of swaddling myself in fleece, I swaddled myself in starvation, exercise, bones, and three layers of hoodies. In a sense, the AN protected me from having to deal with life because the starvation and obsession blunted the sadness and anxiety I so often felt. As long as I was losing weight, or eating a prescribed food plan, or exercising, then nothing else mattered. This happened biochemically, of course, but it also happened in a more nebulous, existential sense. I organized my life around the rules of anorexia.

In a sense, I suppose my OCD rituals and compulsions were also like a soteria. They made the world seem okay. They provided me with a sense, however fragile and fleeting, that I could handle things.

That being said, neither the eating disorder nor the OCD were really a soteria because they weren't a positive analogue to anything. I've never really had lucky socks or a very special token. Outside of the brain disease induced superstitions, I am much more on the dully rational side. And yet I crave the comfort and security of something, of...well, I don't know what. I have a few possessions with an unusual level of attachment (my crochet hooks, my journal, several stuffed animals) that I suppose form sort of what a soteria is. But I can't think of anything concrete, nothing that would counteract the hold of the eating disorder.

I don't know- maybe I don't need something specifically concrete. I would almost prefer something to do, a drive or passion that would overpower the continuing allure of ED thoughts and behaviors, rather than an inanimate object. I'd like to have something, although I'm not sure deliberately looking for a so-called "security blanket" will be the same as just becoming attached to some tatty blanket.

Do you have a soteria? How did you find it?

I thought about including this piece of research in last week's smorgasbord, but I thought it was so important that I wanted to make sure it got its solo time in the limelight.

Determining target weights in people with eating disorders has never been easy. Many doctors lowball the weight so they don't scare off the patient. Which is nice (remember the phrase about the road to hell being paved with good intentions?) but it also really twists the sufferers mind and leaves them only 90% well. No one would settle for removing 90% of a tumor just to make a cancer patient feel better in the moment, so why people are very willing to tolerate sub-optimal target weights is beyond me.

This has been an issue with me because I'm fairly muscular, and I weigh more than I look like I do (a friend described me as small but solid). So the old formulaic 100-pounds-for-five-feet-and-five-pounds-for-every-inch-over left me at a weight where I had already lost my period on the way down. I was more than happy to stay at the inappropriately low weight, not the least because I got to skip out on the monthly tampon shopping sprees. It also left me deeply entrenched in the eating disorder.

There are also other treatment providers who would provide an accurate target weight if only they knew what it was. In younger children, in those who have been sick longer, and in those who don't have growth charts, even the best physician can be flummoxed. The organization FEAST has some good information on setting target weights, as does the Kartini Clinic, and although these methods are informed by science, they are still as much of an art as anything.

But we might have a new tool to help with this. A recent study from the European Eating Disorders Review found more objective ways to help determine target weight in a study titled "Predicting the weight gain required for recovery from anorexia nervosa with pelvic ultrasonography: An evidence-based approach."

The abstract of the study summarizes the outcome of the study rather well:

Transabdominal pelvic ultrasound scanning (U/S) offers a more objective method of ascertaining physical well being by the ability to determine reproductive maturity. This study aimed to explore the correlations between the maturity grading on pelvic U/S and weight for height (WfH) ratios and body mass index (BMI) percentiles. Ultrasound studies were performed in 72 female adolescents (aged 11-17 years at intake) with AN. Scans were graded for maturity using published parameters of pelvic maturity and compared with the patient's WfH ratio and BMI percentile. In our sample was a wide variation of WfH ratios and BMI percentiles at each grade of maturity. This supports the view that arbitrary targets for weight, WfH ratio or BMI percentile are likely to be unnecessarily high for some patients and too low for others. We recommend that targets be based upon baseline pelvic U/S grading and follow-up scanning.

This study will probably need to be replicated before it can become commonplace, but I am so glad that there are now evidence-based approaches for helping to determine target weight that are more effective than a coin toss or one-size-fits-all approach.