It's that time of the week again- the Sunday Smorgasbord! I'm going to try the smorgasbord like I did last week, with more links and less in-depth coverage. Please be sure to let me know what you think of the different format in the comments setting. Thanks!

Fruit fly tongues and feeding behaviors

In class, in treatment: Treating EDs in college

Gene variations in endurance athletes

Emily Program SpeakUP Web Rally on ED Insurance Coverage

Why the body isn't thirsty at night

Bulimia patients show altered body schema and self-representations

Chronological sequences of specific eating and anxiety disorders

Patterns and prevalence of disordered eating and weight control behaviors in women ages 25-45
Caffeine consumption among eating disorder patients: Epidemiology, motivations, and potential of abuse

BBC Breakfast speaks with 12-year-old recovering from anorexia

ED patients show signs of humanity as they have improved self-esteem when treated kindly

Melissa (of the blog Finding Melissa) presents with Prof Janet Treasure in London- click here to download audio and video versions of the talk.

The upside of depression

How the addition of BED may affect employers and insurers

So it's the last day of National Eating Disorders Awareness Week. I'm guessing most of my blog readers are aware of this, and I think improving awareness of eating disorders is a Very Good Thing. There is still so much misunderstanding about eating disorders, and it kind of irritates me. Some things about NEDAW irritate me, too. For starters are the atrocious headlines in ED stories, such as "Anorexia: Starved for Love." Yes, people with anorexia are starved, but they're primarily starved of food. That can cause sufferers to starve themselves of other things besides food, true, and love can go a long way in recovery, but lack of love isn't an eating disorder.

And I'm left with very mixed feelings about the ways in which we try to prevent eating disorders. Much of the information out there is about loving your body and improving self-esteem and why you shouldn't diet--all of which is good information, but I'm not so sure how it prevents EDs (excepting the last bit). The irony is that explaining what EDs are and what the symptoms are and how to help a friend can trigger ED behaviors. Yes, dear, starving yourself and puking are very bad and you shouldn't do them.

No kidding.

I had a friend with anorexia, and I remember distinctly thinking when I first started on my new healthier eating/exercise program that I didn't want to become anorexic. I knew what anorexia was and I knew it was a bad thing. I was aware of eating disorders. Not like I am now, but I knew that looking at fashion magazines was considered Bad for Women and that if I let my (hypothetical) children emote freely and didn't let them have Barbie dolls, then they probably wouldn't get anorexia. Right?

I was--okay, I still am--a bit of a do-it-yourself-er feminist. Raised in a rather conservative family, I stumbled across feminism through surreptitious reading in my American history class in high school and learned, quite possibly for the first time, that feminism meant more than bra burning. I was still in this phase when I had my first initial crash course on eating disorders by way of my best friend in college. I didn't do a whole lot of researching, as this friend was in recovery and not in need of huge amounts of eating support, because I'd Heard The Message. I figured that if I could help my friend get over the evils of wanting to look pretty and have the thin, "perfect" body that was required of her by OMG TEH MENZ!!!!1!, then she would finally overcome the last bit of her eating disorder.

I was so naive.

I knew nothing of biology, nothing of the links to anxiety disorders, nothing of any of this. I had heard the message of NEDAW, essentially, because I thought if I would help people love their bodies then there would be no eating disorders.

Yes, in recent years NEDAW has begun to integrate some science, but in many areas, NEDAW is also called "Love Your Body Week." I'm not against having a "Love Your Body Week" but I'm not sure how it will prevent eating disorders. It's like having the theme of the Depression Awareness Week be "Don't Worry, Be Happy." Rastafarians and reggae music is nice, and it might lift your spirits, but its relationship to depression is unclear.

Yes, many people with eating disorders struggle with body dysmorphia, and learning to accept and live in your own personal body is a major task for people in recovery. I'll admit it's one of mine, learning to move through the world in a body that is chubby round jiggly chunky lumpy not emaciated. It's a major problem for people with eating disorders, and it's not entirely illogical to think that if we can prevent people from hating their bodies, we can prevent eating disorders. Except that extreme body hatred is often the result of an eating disorder (or at least greatly inflated by it), not an actual cause of an ED.

I'm not anti-NEDAW. I'm not anti-Love Your Body messages. If there was a little less overlap between the two topics, I probably wouldn't be quite so bothered.

What NEDAW message do you want people to hear?

I was in the middle of writing another post when I got the ever-appreciated ding that a friend had sent me a message via Facebook chat. I met this friend (let's call her N. to keep her anonymous) in the writing program I was in. We shared a room at a conference and generally got along splendidly because of some similarities in our pasts. Both of us had our share of mental health issues and had spent time in psychiatric units. We discussed our various medications with no small amount of glee. And we both found ourselves struggling after graduation, both of us having difficulty finding our way in the world. We kept in vague touch, although neither knew the full story of what happened with the other person.

So N. asked how I was doing, and I decided to come clean with the story of my relapse and what I was up to now, and I was relieved to hear what kind of support I got. It was so nice to just share what had been going through my mind, and how I felt like our program screw up because of all my issues. And N. said, basically, no, I couldn't be the program screw up because that job was hers. I was just about to assure her that this was one job she was safe resigning from when I had to laugh. It was like those interminable conversations with other people at treatment, as to who was the fattest. And everyone always insisted it was them no matter how often the other girls said that no, they were the fattest ones there. It was a losing argument, and no one ever had an accurate idea of their true shape and size and the end of the discussion, but we always persisted on having them anyways.

Still, it was reassuring to know that someone else was floundering in life and thinking they were a failure and wondering how they were going to be a successful writer when all they could see was this big black wall of FAILURE sitting in front of them.

As I was chatting with N., I was reminded of a visit our program got by someone who had graduated several years previously. She told us of how much of her early career could be described in one word: flailing. All of us in the program laughed nervously, knowing that this experience was waiting for us, too.

And it was. It really, really was.

So I reminded N. about this quote, and I told her: Maybe we're not failing. Maybe we're just flailing.

She agreed and the conversation drifted, as conversations tend to do. We eventually started talking about our current writing projects, me with my freelance projects and her with her novel. Then N. said something rather profound:

Just sitting down to write every day is an act of amazing courage on my part.

I had to agree.

It's hard for me to express to other people just how much courage I have to muster up to get through the day, how much energy it takes to look "normal" sometimes. Sometimes getting out of bed is an amazing act of courage. Eating sure is.

We all have things--courageous things--that we do every single day. Just because they're ordinary doesn't make them any less courageous.

What's your "amazing act of courage"?

So I had planned to do part two of the DSM-V eating disorders series, but that got sidelined by a massive bout of anxiety. I can't think straight. I can hardly sit still. I have chewed my nails into nubbins (not that there was a lot for me to chew, but somehow I managed).

I have a lot of uncertainties in my life: if I'm going to be able to make a go at being a writer, if financially everything will work out, if I'm ever going to be free of this ED, if if if if if.

I hate "if". Tell me "when." Now would be nice.

I spent much of the evening working on my writing projects and getting nothing accomplished because my brain kept zooming from one worry to the next. I eventually gave up and flipped through my newest National Geographic.

In some sense, I'm tolerating the anxiety because I haven't completely imploded. In another sense, I want to just crawl out of my own skin. My mom asked if there was anything she could do to help with the anxiety. I looked at her and said: "Could you get me a treadmill?" It's not even the burning calories part that's attractive--that frenetic movement seemed to exhaust my brain so that it was almost impossible to worry so much. And during exercise, my brain shut off completely.

So I'm going to go try and get some sleep and hope that everything works out.

As I promised two days ago, here are my thoughts on the other changes made to the DSM. I blogged previously about my thoughts related to the changes made about anorexia nervosa, so now it's onto the other diagnoses.

Bulimia Nervosa

The changes to the BN diagnosis were twofold:

• the frequency of binge eating and purging was decreased from 2x/week for 3 months to 1x/week for three months


• the "non-purging" BN subtype was eliminated, and merged with Binge Eating Disorder

The first criteria is pretty straightforward and there is quite a bit of evidence to indicate that so-called "sub-threshold" bulimia is just as severe as "threshold" bulimia in the DSM-IV (Krug et al, 2008; Wilson and Sysko, 2009). This change isn't anything I have any desire to argue with.

The second criteria is more problematic. The drafters of the ED criteria for DSM-V had this rationale about the change:

DSM-IV requires that sub-type (purging or non-purging) be specified. A literature review indicated that the non-purging subtype had received relatively little attention, and the available data suggested that individuals with this subtype more closely resemble individuals with Binge Eating Disorder. In addition, precisely how to define non-purging inappropriate behaviors (e.g., fasting or excessive exercise) is unclear.

Deletion of this subtype is recommended. This also requires rewording of Criterion B.

Criterion B specifies "inappropriate compensatory behaviors," and these behaviors would be limited to self-induced vomiting, and misuse of laxatives and/or diuretics. To some extent, I see the difficulties in defining fasting or excessive exercise- it isn't clear. But my next question would be then to define the "misuse" of laxatives and diuretics. So if you binge and then you can't take a crap and you swallow a few pills, is that misuse? What if the box says take two to four pills, and you always take four because you're convinced that any less wouldn't get the food out. Is that misuse? You're following the directions on the box, after all. If they specified "use" of laxatives and diuretics to specifically try and "undo" a binge, then I wouldn't probably be so prickly. It's clear that it's a purging behavior. But misuse? If the idea is to get rid of unclear definitions, I'm not entirely sure they did that.

My other question is this: I thought fasting and exercise were kind of considered forms of purging. I'm not sure what the distinction is--does purging have to involve your mouth or your butt? Sorry to be kind of crass, but I'm still trying to figure that one out. It's one thing to remove the subtypes and just create a "bulimia nervosa" definition that encompasses both purging and non-purging types, but I'm not positive on the wisdom of removing fasting and excessive exercise from the BN criteria.

The DSM-V draft criteria cited a study titled "The Validity and Utility of Subtyping Bulimia Nervosa," which came to the following conclusions:

Another possible reason for the lack of data on individuals with BN-NP may be a problem in diagnosing these subjects. Individuals who would qualify for the diagnosis BN-NP may go unnoticed or be wrongly diagnosed as BED or ED-NOS as a result of incomplete assessment of nonpurging compensatory behaviors. Both dieting and exercising are common in the general population, and are not necessarily pathological. There is no clear criterion to decide at what point the amount of exercising and dieting exceeds a cut-off point and becomes abnormal. This does not mean that nonpurging compensatory behaviors are clinically irrelevant. A number of studies have provided information that both purging and nonpurging compensatory behaviors are important clinical markers, for example, they both have high rates of comorbidity; their frequency is associated with severe maladaptive core beliefs and they are associated with impaired social functioning. The lack of clear definitions of nonpurging compensatory behaviors combined with their clinical relevance highlights the need for better diagnostic criteria.

Although the number of subjects with BN-NP [non-purging bulimia nervosa] is generally lower than that of BN-P [purging bulimia] and BED, in some studies the rates are comparable to, or in favor of, BN-NP, notably for three of the five general population studies. This may be a result of the more standard use of (semi-) structured diagnostic interviews in this type of study, in which the presence of nonpurging compensatory behaviors is routinely checked. Again, this calls for increased attention to the formulation of clear and easy to apply diagnostic criteria for nonpurging compensatory behaviors.

The study called for one of three possible solutions to this subtyping issue:

1. Maintain the current situation by keeping BN-NP as a subtype separate from BN-P as in DSM-IV, that is, a distinction between purging and nonpurging types of compensatory behavior in people who binge eat.


2. Eliminate nonpurging compensatory behavior as a diagnostic criterion. Individuals
   receiving a diagnosis of BN-NP in DSM-IV would be designated as having BED.


3. Inclusion of BN-NP in a broad BN category, as suggested by Walsh and Sysko, where a combination of binge eating with only nonpurging forms of compensatory behavior would be considered an atypical form. This would require a clear definition of the normal/abnormal boundaries of food restriction and exercising.

Obviously, the decision was made in favor of option 2.

How the specific vagaries of diagnosis will affect treatment remains to be seen. The irony is that most treatments for BED recommend physical activity--which is fine, but not for someone who uses exercise as a compensatory behavior. The debate isn't settled, and I'm not sure what I would do myself if I got to have the DSM Magic Wand.

Binge Eating Disorder

Binge eating disorder was included, which was a HUGE victory (no pun intended). BED is been fairly well defined for quite some time, and there are specific treatments that can help people struggling with binge eating.

The frequency of binge eating was specified at 1x/week for three months to make it more in line with the BN diagnosis. This seemingly low threshold for binge frequency has gotten some people up in arms. Writes psychiatrist Allen Frances in an article titled "Opening Pandora's Box":

Binge Eating Disorder will have a rate in the general population (estimated at 6%) and this will probably become much higher when the diagnosis becomes popular and is made in primary care settings. The tens of millions of people who binge eat once a week for 3 months would suddenly have a “mental disorder”― subjecting them to stigma and medications with unproven efficacy.

This is certainly a valid concern (a diagnosis should adequately capture all people who are ill with a disorder and none of those who aren't), but just because a diagnosis is more common doesn't mean it's not real. Also, the problems with people being subjected to medication seems more of a problem with our messed-up health care system and non-specialists making rather specialized diagnoses (I wouldn't want my cardiologist trying to diagnose my foot problem) than with the actual diagnostic criteria.

If the criteria for BED was just one binge a week for three months, I'd be much more willing to concede Dr. Frances' point. However, there are other criteria for BED that include feeling overly guilty or disgusted with oneself; the feeling of not being able to stop eating; feeling depressed afterwards; etc. Occasional overeating is unlikely to happen alone and result in "marked distress."

Still, Frances' overall argument is interesting and timely and well worth reading.

Purging Disorder

Rachel at The F Word pointed out the lack of formal inclusion of purging disorder in the DSM-V by highlighting this paragraph from the EDNOS section:

The work group is considering whether it may be useful and appropriate to describe other eating problems (such as purging disorder–recurrent purging in the absence of binge eating, and night eating syndrome) as conditions that may be the focus of clinical attention. Measures of severity would be required, and these conditions might be listed in an Appendix of DSM-5. If these recommendations are accepted, the examples in Eating Disorder Not Otherwise Specified will be changed accordingly.

I'm not surprised that purging disorder didn't make it in as a stand-alone diagnosis, not because the data isn't good--it is--but that it's rather new. Rachel has a whole post devoted to purging disorder that is well worth reading, and you can find more studies on purging disorder here.

A few weeks ago, I posted on the draft criteria for eating disorders proposed for the DSM-V, and I promised you my thoughts on the changes (or lack thereof). I spent several days mulling over my thoughts, and then I spent the rest of the time following the ongoing discussion on an eating disorders listserv. The discussion still hasn't concluded, but since it doesn't show any signs of slowing, I decided to bite the bullet and get on with it.

As an overly brief summary, the three most major changes to the current DSM diagnostic criteria for eating disorders were:

• removing amenorrhea as a criteria for anorexia
• removing the purging/non-purging subtypes for bulimia (non-purging bulimia would be considered, essentially, binge eating disorder)
• the addition of binge eating disorder as a stand-alone diagnosis

First off, I want to credit some other awesome bloggers for their thoughts on these changes. Both Rachel and Kim had some thoughts that are well worth reading, and I highly encourage you to do so.

Since I have many thoughts, I decided to break this post into several parts. I decided to start with anorexia, since that's where I have the majority of my thoughts, and I will post the next part on other diagnoses tomorrow.

Anorexia Nervosa

The removal of the amenorrhea criteria is, in my mind, a really good thing. I have no quibbles with that. What is rather interesting is what stayed the same. Both my regular readers Cathy and Katie pointed out that the "overvaluation of weight and shape" isn't universal to anorexia, nor is it necessarily what is driving anorexia. In Kim's blog on the DSM-V criteria, she writes:

In my opinion, the DSM doesn't really do service to the underlying drivers of anorexia. I think most self-destructive behaviors are a way to self-medicate, and I'm very aware that my anxiety went way, way down when I was heavily involved with my eating disorder. Everything seemed very peaceful and quiet when my mind was just tallying calories. For me, recovery is about learning to manage anxiety in a healthy way. It has very little to do with appreciating the Dove beauty campaign. Yes, there are days when I "feel fat," but this mostly translates to "I feel stressed." Somehow, they got linked in my mind (stress-->fat-->eat less-->less stress), but that doesn't mean the driver is for me to be thin; the driver is for me to be calm, and thinness was the result.

The DSM sort of supports the idea of Ralph Lauren ads and anorexia being paired. I just don't see this. This direct linkage seems to fuel the fire that eating disorders are adolescent obsessions with looking good. That fuels another fire -- that treatment is simple: Just eat, write body affirmations, paint your nails, you'll be fine. This starts a whole other inferno of self-hate and shame for the sufferer who feels like, "Why can't I just get better then? Am I just a vain, stubborn idiot?" The only thing that has extinguished all this has been to realize (with the help of Carrie's blog) that this is an illness.

All I can add to this is: amen!

What generated the most discussion on the listserv was the "85% of ideal body weight" criteria for anorexia. Laura Collins pointed out that anything under an individuals ideal body weight was a sign of malnutrition, so it almost seems like the 85% criteria was written by anorexia, for anorexia. Others have pointed out that these criteria leave out people who started restricting at a higher body weight, indicating that they don't have anorexia when all other signs say that they do, indeed, have anorexia. One could say that this is what EDNOS is for, but there are several problems with this. The first is that if they really do have anorexia, numbers on a chart be damned, they should be diagnosed with anorexia. The second has to do with EDNOS and mental health parity. Technically, there's mental health parity in the United States, which means mental illnesses need to be treated on par with physical illnesses (why they're even separated is beyond me, but that's another post). It's a step, and I'm happy it's a step, but let's be honest: everyone knows that mental health care gets the short end of an already very short stick. And in some states, EDNOS is not a parity diagnosis; only anorexia and bulimia are. So these semantics can have huge effects on who gets treatment.

Another issue is that people with eating disorders get very fixated on the 85% "rule." The psychology of EDs works like this: people with lower ideal body weights are somehow "better" and they "deserve" treatment. So if you don't meet that 85% cutoff, many people's thoughts are to lose more weight. I'm not saying we should change the diagnostic criteria to make sufferers happy--this thinking is an issue with ED psychology and not so much the diagnosis. But I'm not so sure what is "magic" about the 85% cutoff. It's not like I hit X pounds and I went from not-anorexic to anorexic, nor did I stop having anorexia once I crept over that 85% mark.

I have almost conflicting feelings on the focus on weight in the ED world. On the one hand, if everyone is weighing me all the freaking time, it's hard to stop focusing on weight. On the other hand, being weighed regularly gives me some comfort because I know I'm not constantly gaining weight. And for someone with a long history of anorexia, tracking weight can be a useful tool. It's not the be all, end all of my treatment and recovery, but if my weight starts slipping, that would be a useful thing to know. Part of the reason I find weight monitoring* helpful is that I'm not necessarily the brightest lightbulb in the box when it comes to recognizing relapse. How can not eating be a problem when it seems like a solution?

I do believe (and evidence suggests) that our bodies gravitate towards our set point weights, but getting there is far from just letting "gravity" do the work. After this past relapse, it took me almost half of my time re-feeding to get the last five pounds on because my metabolism started seriously fighting back. I would have much preferred not to bother with that, but I was lucky to have a team that absolutely insisted. I don't necessarily want people to totally ignore my weight, to just let nature sort itself out. Long-term, ongoing malnutrition wrecks havoc with your body, and that's not something on which I want to take a let's-just-throw-the-dice-and-see-what-happens approach.

That being said, "ideal weights" and "target weights" may not be stagnant, and they may not be one particular number. One treatment center told me my ideal weight down to the half pound, which made me laugh even then. Weight isn't the sole indicator of health. I don't think weight should be ignored, but it's just one factor in an overall picture.

And on that note, I will transition to the last part of my thoughts on the anorexia criteria in DSM-V. The entire DSM was altered slightly to have a dimensional aspect to diagnosis rather than a categorical. Click here for a more in-depth discussion. Take depression. In order to be diagnosed with depression, you have to meet five of nine symptoms. If you don't meet all five, technically, you don't have depression. That's the categorical diagnosis: you have it, or you don't. (Talk about black-or-white thinking!) The problem is that people can suffer from four of the criteria in very severe forms that impact their life. So now the DSM is also looking at severity of symptoms when using the diagnostic criteria so that the hypothetical person in the above example will be diagnosed and treated for depression. Which is good.

As part of this, the draft criteria for anorexia included a "severity" section. You know how severity of anorexia is likely to be calculated? Wait for it...wait for it...BMI. That's right. From the professionals who are constantly saying "it's not about the weight" are the ones telling you that the less you weigh, the sicker you are.

I'm not going to say that health and weight have nothing to do with each other. People with anorexia nervosa and very low body weights are clearly ill. I'm not disputing that. But weight is not the sole indicator of health or severity of anorexia!! There are so many other ways to measure severity, ways that don't collude with the I'm-not-that-sick mentality so common in eating disorders. I have been very, very sick at relatively normal weights, and some of the sickest people I met weren't those with the lowest weights. Anorexia is a mental illness, no? It's not primarily a disorder of low body weight; it's a disorder of self-starvation. Yes, weight loss is part of that, I'm not denying it, but perhaps severity could be measured by things like bradycardia and orthostasis, by body temperature and cyanosis, by energy imbalance and Eating Disorders Inventory scores, by how much of your thinking is dominated by food and weight and how frightened you are of gaining weight. But not weight itself. The severity of binge eating disorder isn't measured by BMI, it's measured by number of binge episodes per week. It can't be that hard to come up with a similar criteria for anorexia...can it?

I am actually shocked that more people haven't noticed and discussed this. It seems like such a huge issue (no pun intended), and it's basically been overlooked.

*Currently, I do weekly weigh-ins and I would imagine these will be spaced out as I continue to do well in recovery.

I'm going to try a little different format for this week's smorgasbord--let me know in the comments what you think of the new style!

Identifying Childhood Risk Factors for Anorexia Nervosa (via Eating Disorders Review)

The Man Who Looks Inside Anorexics' and Bulimics' Brains (a profile of Dr. Walt Kaye, aka my "homeboy")

Connecting the Dots: Stress and Eating Disorders (Part One, Part Two, Part Three)

Craig Ferguson's hilarious rant on fat prejudice (the relevant part starts at 3:25)

Mice Selectively Bred for Excessive Exercise or Obesity have Dopamine Abnormalities in their Brains

PANDAS and anorexia nervosa: a spotter's guide

Brain activation when looking at distorted self images varies based on ED diagnosis and subtype

Two Utah women fight eating disorders together

Fluctuating blood glucose levels may affect decision making

Ice dancer gains weight, performs better. World stunned.

Bulimia nervosa with history of anorexia nervosa: Could the clinical subtype of anorexia have implications for clinical status and treatment response?

What fruit flies and mice can teach us about emotion

Family of anorexic told "she'll get better when she wants to get better." She dies first.

And last, but not least: Today marks the kickoff for National Eating Disorders Awareness Week 2010.

A new post on the "You Must Be Hungry" blog at Psychology Today looked at the relationship between eating disorders and autoimmune diseases, as well as potential treatments in the form of probiotics (healthy bacteria, like the kind in yogurt). Writes author Shelia Himmel:

Enter NuBiome, a company founded in 2009 to develop therapies, including probiotics (beneficial bacteria) that interfere with disease-causing bacteria found in the gastrointestinal tract, focusing on autoimmune conditions. The company founders all have seen or had family members who got sick with autoimmune diseases. That includes bulimia and anorexia.

"The paradigm's got to change," said Brian Lue, a NuBiome researcher. In a paper he delivered recently, Lue explained how people used to think that stomach ulcers were caused by stress and dietary choices.

...Lue explains, "A normal person with a normal immune system may have a rare event in their intestine and this changes the way the normal bacteria in their gut die and break up into fragments. Their immune system then finds a specific piece of the bacteria that looks like a piece of the insulation on their nerves. Now, when the immune cells find that piece of insulation on the nerves, bad things start to happen. The body's immune system turns against nerve insulation because it "thinks" that they are foreign bits of bacteria. In the process it ends up destroying its own tissue because it confuses body tissue with that of the bacteria. This is what an autoimmune disease is. In the case of multiple sclerosis, the insulation on the nerves is attacked by the person's own immune system."

How does all this relate to eating disorders?

Lue refers to a 2005 paper in the Proceedings of the National Academy of Sciences by Serguei Fetissov, who identified specific antibodies in people with anorexia and bulimia nervosa. These antibodies disrupted the normal hormonal systems of the brain, particularly the part of the brain that is responsible for appetite control and the stress response.

Lue writes, "This seems to correlate with the changes in eating habits that defines bulimia and anorexia. The authors of the study suggested that the autoimmune response could be triggered by pieces of several types of bacteria in the gut mimicking the brain hormones. Pieces of H. pylori, the stomach ulcer bacteria, and E. coli are some of the likely suspects."

I'm a long way from saying that yogurt is some magical cure-all for eating disorders (though I do loves me some yogurt), but the research is interesting.

I had previously downloaded the 2005 Fetissov paper that Himmel mentioned in her blog post, titled "Autoantibodies against neuropeptides are associated with psychological traits in eating disorders," and re-read it for this post. The researchers knew from previous research that people with AN and BN had antibodies to α-melanocyte stimulating hormone (Fetissov et al, 2002), known as auto-antibodies because they were antibodies against "self" proteins, and the authors of the 2005 study note that:

melanocortin peptides involved in appetite control and the stress response. In this work, we studied the relevance of such [auto-antibodies] to AN and BN. In addition to previously identified neuropeptide autoAbs, the current study revealed the presence of [auto-antibodies] reacting with oxytocin (OT) or vasopressin (VP) in both patients and controls.

Which is interesting, when you look at the roles of both oxytocin and vasopressin and consider that difficulties with social relationships and stress, respectively, are pretty common in eating disorders. What is also interesting from this study are the differences in auto-antibody levels in AN and BN. In AN, higher levels of auto-antibodies were correlated with higher scores on the Eating Disorder Inventory-2 (meaning higher levels of ED psychopathology), while in BN the opposite was true: higher levels of auto-antibodies meant lower levels of ED psychopathology, and vice versa. (If I'm reading the statistics wrong, please someone let me know- it's been a long time since I had to puzzle through dense biostatistics jargon.) What this difference ultimately means is beyond me, although I hope more research will look into the subject.

At the end of Himmel's blog post, she mentioned that a NuBiome researcher asked about her daughter's (who had anorexia and bulimia) childhood exposure to antibiotics, and Himmel recalled that her daughter had frequent doses of antibiotics. Granted, so did I, for frequent lung infections aggravated by asthma that left me with a 10-pack-a-day smoker's cough at the age of 6. However, antibiotics were peddled like candy when I was younger, and furthermore, EDs existed long before penicillin. Nor was I able to find any research indicating a link between antibiotics and the onset of eating disorders.

Still, the research is interesting and thought-provoking, and I'm curious to see more. I'm also getting a strange urge to hit the dairy case, so if you'll excuse me...

This post will be short, since I'm rather crunched on time, but I couldn't let this little bit of research pass by without mentioning. The study, titled "Binge eating disorder: a symptom-level investigation of genetic and environmental influences on liability," was published in Psychological Medicine and found that approximately 45% of your risk for developing binge eating disorder was due to genetic factors.

(As a quick but important aside, the "45% of your risk" bit doesn't mean that 45% of people with BED have the disorder because of genetic factors and 55% have it for other reasons. Nor does it mean that 45% of your "risk" for developing BED is genetic and 55% is due to environmental/cultural factors. What it means is that 45% of the reason that one person has BED and another doesn't is their genetic differences. Class dismissed. There may be a test.)

Not that this isn't important and interesting--which it is--but what I found interesting was how the authors looked at inheritance of BED. Rather than looking at BED as a distinct entity, they looked at the heritability of the individual symptoms of BED, such as loss-of-control eating. It turns out that over the past decade, research into the genetics of EDs has begun looking at the heritability of specific symptoms of these eating disorders (Klump, Kaye, and Strober, 2001) rather than "anorexia nervosa" or "bulimia nervosa."

Don't get me wrong- no one ever expected to find an anorexia gene or a bulimia gene. That's just not how the body works. But the thinking was that genes influenced susceptibility to anorexia, bulimia, etc. In fact, behavioral geneticists have been looking how the different symptoms of EDs are inherited. No doubt some frequently travel together, which is why we do see distinct patterns in eating disorders. But there's also a fair bit of heterogeneity in eating disorders, in that most people don't fall into a strict diagnostic category. Besides saying that our diagnosis of EDs sucks, this factor says we don't really know what's going on beneath the veneer of ED symptoms.

I don't know the answer to this, but it's an interesting question.

(I am shrugging off the I'm-a-Bad-Blogger feeling for writing such a hastily thrown together post that's short and doesn't delve into the issues very well. I apologize if any of you were disappointed!)

Seeing as I have finally (!) found a new therapist in my new location (who also accepts my insurance and is only an hour drive away), who I meet with on Saturday, and there have been several good posts about finding a good therapist and effective treatment, I decided a blog post would be appropriate.

Dr. Sarah Ravin has a list of five questions to ask a potential therapist when seeking treatment:

In regards to your question, here are the five important questions (in my opinion) that one should ask a potential therapist when seeking treatment for a serious, long-standing eating disorder:

1.) In your opinion, what causes eating disorders?

(Make sure they have a science-based explanation that involves neurobiology, genetics, personality traits, and the role of malnutrition. It’s OK if she mentions societal pressures for thinness as triggers, so long as that’s not the ONLY thing she mentions.)

2.) Describe your philosophy of treatment for eating disorders.

(Make sure she emphasizes full nutrtion and weight restoration to ideal body weight (for AN) and nutritional stability / cessation of binge-purge behaviors (for BN) as the first step in treatment. Make sure she also emphasizes the acquisition of coping skills, learning to eat healthfully and independently, self-care, treatment of co-morbid conditions, and relapse prevention)

3.) Describe your training and experience in empirically-supported treatments.

(Make sure she has some training and/or experience with CBT, DBT, ACT or other third-wave behavior therapies, and/or Maudsley FBT).

4.) How many patients with eating disorders have you treated in the past three years? How many of these patients have fully recovered?

(Make sure she’s seen at least a few other people with EDs, and make sure that the majority of them are fully recovered (or at least well on their way to recovery).

5.) What is your opinion on the involvement of family members and significant others in the treatment of eating disorders?

(If she advocates parentectomies or exclusion of family members, or implies that families cause EDs, this is bad news. If she views family members as potential emotional or nutritional support for the patient, this is good news).

If there is one word in reading about a therapist's history and treatment philosophy that gives me the heebie-jeebies and automatically makes me click "NEXT!" is this: eclectic. I shudder just typing it. To me, eclectic says "I do whatever I feel like doing" or is kind of like commitment-phobia for the potential therapist. You're a professional- tell me what works and why. There's a difference between "eclectic" and "I have been trained in approaches A, B, and C and can help tailor therapy to you and your situation." I have found a combination of CBT, DBT, and FBT to be helpful at various stages in my recovery, so I'm not all-or-nothing about types of therapy. But eclectic? Ick.

The Cleveland Center for Eating Disorders blog "Living With Food" has this advice for seeking evidence-based treatment:

1.Remember that there are very few evidence-based treatments for eating disorders. If you are not receiving cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, or family based therapy, then the odds are very high that you are not getting evidence-based care.

2.Your primary care physician is likely to have experience with patients who have done different types of treatment in your community. Your primary care physician is therefore a critical resource.

3.When you are in a provider’s office and they are discussing care options with you, never hesitate to ask for all of the evidence behind what they are saying. At this point in time, all practitioners in eating disorder treatment should be able to back up what they are saying in a straightforward and understandable manner.

4.Finally, while doing research on treatment for eating disorders, the Internet, while helpful, may not provide definitive answers (and may be more confusing than anything). There are certain organizations that we feel are trustworthy. We highly recommend NEDA, AED, Maudsley Parents, ED Recovery, The Freed Foundation, Are you eating with your anorexic, The F-Word, NAMI, Life After Recovery, and FEAST as reliable organizations and blogs where you can learn about evidence-based care and communicate with other patients and families that may be struggling with an eating disorder.

Off course, point #2 assumes your PCP/GP isn't a total bonehead and doesn't blow off your concerns. Still, they should know something about community resources or have a referral to someone who isn't a total bonehead. When all else fails, go straight to point #4.

There are plenty of other barriers to finding quality ED care, not the least of which are: geography, therapist's availability, insurance coverage, wait lists, finances, you name it.

What criteria do you use when looking for a therapist (or what criteria would you use)? Do you have any words or phrases that are a therapist "turn off"?

I have watched this Cat Turf War video almost ten times today, and it never ceases to make me fall out of my chair laughing. So for all of you to enjoy, here's the video:

A recent study from the Journal of Bone and Mineral Research found that women with anorexia had much higher levels of fat in their bone marrow than women without AN (Ecklund et al, 2010). The study was generally publicized as "OMG! Anorexics have FAT on their bony bodies!" Which, as an interesting irony and news hook, I'll give you. But the story goes much deeper than that, which some of the news coverage touched on but really didn't delve into (they appeared to get stuck on the "WTF- could anorexics be fat?!?" part).

Eating disorders are associated with an increased risk for osteoporosis--and it ain't no joke. I've learned that the hard way, with three broken bones and several stress fractures. There are many hypotheses for this increased risk, including deficits in estrogen, high levels of cortisol, and high levels of leptin. I'm guessing each of these plays a role in the decrease in bone mass and density through either the metabolism of bone cells and/or a dramatic decrease in the formation of new bone cells during malnutrition.

This study points to a new mechanism for the dramatic bone density decrease seen in eating disorders in general and anorexia in particular. At the center of larger bones is the bone marrow, one type of which is the red bone marrow and produces new blood cells. The other type is the yellow bone marrow and contains fat cells that can be used as an energy source in cases of extreme starvation. Furthermore, the two types of bone marrow can be interchangeable--in cases of extreme blood loss, the yellow marrow can be converted to red marrow. What Ecklund et al found in this most recent study is that red marrow can be converted to yellow marrow if the body is profoundly starved, which can result in premature osteoporosis.

The study subjects with anorexia had much higher levels of yellow marrow than red marrow, and the researchers hypothesized that the body had prioritized the formation of extra fat for future energy needs at the expense of red blood cell formation (I'm wondering whether this also helps to explain the high levels of anemia seen in people with eating disorders). The innate intelligence of the body never ceases to astound me. In a starving person, fat (which is essentially energy) is much more useful than red blood cells. Without energy, the body shuts off. With fewer red blood cells, you may be more easily fatigued, but mild levels of anemia are rarely out-and-out life threatening.

It will be interesting to see if there is follow-up research done to see how weight restoration and recovery change the ratio of red and yellow marrow, and whether these changes persist for a long period of time after recovery.

Sit back, relax, and enjoy this week's smorgasbord!

Classification of eating disorders in children and adolescents

As I mentioned earlier this week, the draft version of the DSM-V was released. In addition, a research article was published in the European Eating Disorders Review about proposed changes to diagnostic criteria for EDs in children and adolescents. Says the working group:

The consensus opinion of an international workgroup of experts on the diagnosis and treatment of child and adolescent eating disorders is that (a) lower and more developmentally sensitive thresholds of symptom severity (e.g. lower frequency of purging behaviours, significant deviations from growth curves as indicators of clinical severity) be used as diagnostic boundaries for children and adolescents, (b) behavioural indicators of psychological features of eating disorders be considered even in the absence of direct self-report of such symptoms and (c) multiple informants (e.g. parents) be used to ascertain symptom profiles. Collectively, these recommendations will permit earlier identification and intervention to prevent the exacerbation of eating disorder symptoms.

And since earlier intervention means (in general) better outcomes, these changes may help prevent ED chronicity.

Anxiety Disorder Impairs Emotional Control

Thus was the title of a PsychCentral news story on an article from the American Journal of Psychiatry titled "Failure of Anterior Cingulate Activation and Connectivity With the Amygdala During Implicit Regulation of Emotional Processing in Generalized Anxiety Disorder." The lead author on the study said that (quoting from the PsychCentral story):

“Patients experience anxiety and worry and respond excessively to emotionally negative stimuli, but it’s never been clear really why,” said Amit Etkin, MD, PhD, acting assistant professor of psychiatry and behavioral sciences and first author of the study.

Etkin said clinical data have suggested that adult GAD patients initially register negative stimuli in a largely normal way, but have deficits in how they then control negative emotions.

...For the study, Etkin recruited 17 people with GAD and 24 healthy participants and used functional magnetic resonance imaging and a behavioral marker to compare what happened when the two groups performed an emotion-based task.

The task involved viewing images of happy or fearful faces, overlaid with the words “fear” or “happy,” and using a button box to identify the expression of each face. Not all the words matched up — some happy faces featured the word “fear,” and vice versa — which created an emotional conflict for participants.

...in the GAD patients, the reaction-time effect seen in healthy patients was absent — and in the most anxious patients, reaction time actually worsened when there were two incongruent images in a row.

“GAD patients had decreased ability to use emotional content from previous stimuli to help them with the task,” said Etkin.

He said the differences between the two groups were striking. “By looking at reaction times alone, we could classify who was a patient and who was a control,” he said, adding that this represented the first solid demonstration that a psychiatric population has a deficit in a form of unconscious emotion regulation.

This is especially interesting to me as previous research has suggested that difficulties with emotion regulation also accompany eating disorders. No one knows in what ways these difficulties are similar or different from GAD, but it seems an interesting area of research.

Exercise/Depression Link

I initially got hooked on exercise, oh so many years ago, because I found it a good way to decrease my anxiety and improve my mood. Which wasn't a bad thing, and it took several years (and the formal onset of my eating disorder) before my exercise habits approached anything resembling pathological. But research has shown that people who exercise regularly are less likely to report symptoms of depression than those who don't exercise regularly. (Of course, it could be that depression makes it damn hard to do anything, including exercise, so these data don't necessarily say a whole lot.) Other studies done where people with depression were randomly sorted into two different groups, one of which used exercise to augment the action of anti-depressants, and one with anti-depressants alone. And the addition of exercise did seem to improve depression.

For me, exercise was a weight loss strategy, yes. But that's not how I got hooked. I got hooked because exercise made me feel better. Here's a rather technical explanation how exercise affects the brain, from a longer story on using exercise to help treat depression:

One possible mechanism whereby exercise alleviates depressive symptoms involves the idea of an adaptable and ever-changing brain. Human imaging studies show that major depression correlates with decreased hippocampal volume; the magnitude of the change in hippocampal volume is directly proportional to the length of illness. Up to a 19% loss in hippocampal volume may occur in persons with severe, untreated depression.

Among persons who exercise and are treated with antidepressants, one sees the opposite—hippocampal volume increase. In this context, it is interesting that (at least in rodents) exercise increases levels of brain-derived neurotrophic factor (BDNF) in the hippocampus and cerebral cortex. Associated with this up-regulation of BDNF and other neurotrophic factors, exercise increases neurogenesis in the hippocampus in a manner similar to what is seen with antidepressant treatment. Endurance training (in animal models) increases cortical capillary supplies, number of synaptic connections, and development of new neurons.

I would never say that moderate/regular exercise is bad, and I do think that movement can help with symptoms of depression and anxiety, but it would be nice if people understood that the same reasons that exercise helps with depression can also make it rather addictive.

Drinkin' Ain't Chicken Pox

...or is it? A wonderful, brilliant, funny post from The Tao of Chaos looks at whether alcoholism is a disease.

So what’s this whole “alcoholism is a disease” thing, anyway? I thought a disease was something you catch, like chicken pox or leprosy. When I drank, I got money, went to the store, bought some alcohol, brought it home, opened it up, and drank the alcohol. That doesn’t sound like a disease to me.

So why does the concept of alcoholism as a disease still ring true to me?

...[Alcoholism] acts like a disease, it damages and destroys lives like a disease. Diseases need treatment. Treatments have variable outcomes and variable prescriptions. Back to the medical professionals: ask them and you will find that the treatment for a given disease is effective for most; some demand alternate treatments for one reason or another...Whether or not you buy the disease theory, keep this in mind: if it waddles like a duck, has feathers like a duck, has a beak like a duck, it might be a duck. Even if you’re wrong and it’s a goose, it still browns up nice in the oven like a duck.

Eating when hungry improves health and works better than dieting

We will now pause while the scientific/health/medical world dies of shock. From the abstract of a paper titled "Sustained self-regulation of energy intake. Loss of weight in overweight subjects. Maintenance of weight in normal-weight subjects." :

Over a 5 month period [a pattern of meals that began with hunger before eating] resulted in significant loss of weight in [overweight] subjects compared to controls practicing dietary restraint. [Normal weight] subjects maintained weight overall, however [normal weight subjects with lower pre-meal hunger] also lost weight compared to controls.

(I apologize for the odd wording- the authors of the study used a LOT of abbreviations, and I tried to get the general idea across without adding several paragraphs of information.)

I hope you enjoyed your smorgasbord! Stay tuned for next week's collection of tasty tidbits and delicious morsels.

Many people with eating disorders report a "voice" in their head that tells them to starve, to binge, to purge, to exercise. This voice hisses and spits while they look in the mirror and try on clothes. It congratulates you on every pound (half-pound, quarter-pound) lost. Jenni Schaefer calls her eating disordered voice "Ed," and considers it separate from herself. Ed is the voice of an eating disorder, and not the voice of Jenni.

I think this can be a tremendous therapy tool, and have tried it myself, except for one tiny detail: my eating disordered voice sounds exactly like me. I can be sitting in the car and driving, trying to figure out how many miles I have left before my destination, whether I should pull through the car wash, whether I might need the oil changed, and slide seamlessly into a diatribe of self-loathing about how much I ate and how much more I should have exercised. It sounds like me and it talks like me and it can talk for me...so is it me?

What makes it even harder for me is the fact that I've been hearing this voice, in one form or another, since long before I ever had an eating disorder. It was the voice that told me I was a loser because I couldn't write the cute bubble letters like the other girls my age and that no one would like me. It was the voice that scolded me for not getting a perfect score on my spelling test. It was the voice that said no one would ever want to be my friend, so I may as well get over it. It was the voice that told me my high school graduation honors were a matter of luck.

If I could condense down everything the voice told me into one simple phrase, it would be: No, don't. Should I go to the party? No, don't. Should I eat that cookie? No, don't. Should I speak up? No, don't. Should I break out of my routine? No, don't. Should I buy those jeans/that book/that expensive bar of chocolate? No, don't. It's a life of "No, thank you, I shouldn't, I couldn't, I would never." There are situations when this is a sensible path to take--it tends to protect personal safety, and that's not a bad thing. But when that's your life, when that's all you know and all you will let yourself know, it's not quite so universally positive.

I was at a get-together last night with a friend of mine. I was visiting L for the weekend (I'm sitting on her floor as I write this), and she was invited to a small party with some friends of hers, and I tagged along. I had previously met almost all of the people there, and they were all really nice people. I knew that weren't judgmental or anything--that wasn't what I was worried about. I hesitated to join in on the conversation because I was afraid I would say something stupid, afraid I would offend someone. Should I join in on the talk? No, don't. It was when someone broke out the karaoke machine that I really started to shut down. I didn't know many of the songs, and even when I did find a song I remembered, I knew I would never ask to sing it. I was too afraid of embarrassing myself. The other girls who were singing seemed to have quite a bit of talent, and I was certain I would sound rather terrible next to them. I can't belt out lyrics- my voice just doesn't seem to go that loud. The clincher was the fact that the computer system gave you a score at the end of your song. I was certain that I wouldn't get the highest score, and I knew that if I didn't, I would hate myself. So I didn't sing.

There was a part of me that just didn't feel like standing up and singing, which is fine, but I've never really been able to cut loose, be goofy, and just have fun. I'm always thinking ahead and anticipating what might be next, how I could look like an ass. Although these thoughts have nothing to do with food and weight, they still seem like a product of the anorexic voice, of the perennial chatter I hear in my head that seems to come from within.

Perhaps one of the hardest parts is this: it's not always mean. Sometimes, the voice is kind and reassuring, like "Yes, I know. It's okay. I'll do better tomorrow." The unsaid piece is that there will be hell to pay if I don't shape up, but still, I'm not berating myself, I'm encouraging myself to do better, to eat less, to exercise more, to study harder. Most of my major relapses started out this way: I started to cut back on food, and if I slipped up, I gave myself a pat on the back and said that tomorrow would be a better day. As the relapse progressed, the voice became harsher and more demanding.

It turns out I'm not the only person with anorexia who has seen this progression. A recent study in Psychology and Psychotherapy asked anorexia sufferers to describe their experiences living with the "anorexic voice" and found that:

These data underlined the positive and negative attributes individuals bestowed upon their anorexic voice; the former appeared stronger during the early stages of their eating disorder, the latter coming into force as it developed. In spite of their voice's harsh and forceful character, participants felt an affiliation towards it. The bond between individuals and their anorexic voice could explain their ambivalence to change. Therapists must persist in their endeavours to penetrate this tie, whilst acknowledging the hold this entity has over those with anorexia. Interventions that address this component of the eating disorder could prove fruitful in helping people towards recovery.

I'm not sure I have a quote-unquote "bond" with the voice in my head, but I do know I'm used to it, and its presence doesn't really bother me. Furthermore, I find it hard to say for sure whether this voice is external or internal. Since it seemed familiar even at the outset of the eating disorder, it feels like it's always been there, even if I wasn't harping at my food intake and weight. It seems ultimately like a perfectionistic voice that happened to become utterly myopic about food and weight.

Do you have an ED voice? How do you experience it? In your comments, I want everyone to feel they can be open and honest; however, I'm also aware that such discussions can be triggering, so keep that in mind as you share. Thanks!

The Opening Ceremonies for the 2010 Winter Olympics were held tonight, and to be honest, I didn't watch. In fact, I had no real desire to watch. I used to love the Olympics, love the festivities and the hoopla and yes, the competition. Watching the figure skating competitions in 1988 inspired me to take lessons myself (a rather short-lived experience given my proclivity to falling). But over the past few years, the joy of watching the Olympics has kind of gone away for me. No longer do I just see the close calls, the amazing costumes, the gathering of people from all over the world. Now I see how much people have tortured themselves to be there, that athleticism is only a mask for an eating disorder.

An article in yesterday's New York Times, titled "For Ski Jumpers, a Sliding Scale of Weight, Distance, and Health," only cemented my decision.

Once the V-technique came into vogue in the 1980s, replacing the classic style of holding the skis parallel, jumping became more dependent on flight dynamics like lift and drag than on the propulsion force of the athletes, experts said.

Body weight became a critical factor. The lighter a jumper was, the farther he could jump. Depending on the size of the hill used in competition, jumpers said, a weight loss of a kilogram, or 2.2 pounds, could result in added distance of two to four meters, or 6 ½ to 13 feet.

As an unintended consequence, ski jumping — which permits only men to compete in the Olympics — became troubled by athletes with extremely low body weight and eating disorders more commonly attributed to female gymnasts and figure skaters.

Beginning in the 1990s, many jumpers risked health for aerodynamic advantage. One study found that 22 percent of the ski jumpers at the 2002 Salt Lake Games were below the minimum height-weight proportion, or body mass index, recommended by the World Health Organization.

There have been several highly publicized cases of anorexia and bulimia among jumpers and apparently even a self-referential song. Samppa Lajunen, who won the 2002 Olympic Nordic combined event, which involves ski jumping and cross-country skiing, belonged to a band whose hit, “The Lightest Man in Finland,” mentioned rumors of eating disorders, according to David Wallechinsky’s “The Complete Book of the Winter Olympics.”

“Women’s gymnastics, you hear a lot that maybe they have problems,” said Alan Johnson, the executive director for Project X, the developmental United States ski jumping team. “I look at all of them and those girls are way fatter than ski jumpers.”

True, that last comment wasn't exactly tactful, but the comparison did make me stop a bit. Not that being thinner than a gymnast is a requirement for having an eating disorder, but still.

Nonetheless, I think the article raises a really important point: it's not just figure skaters and gymnasts (ie, young women whose bodies are judged) who are at high risk of developing an eating disorder. And often, athletes who develop eating disorders often say that they initially wanted to lose a little weight so they could compete better. It's a take-one-for-the-team attitude that can become so self-destructive.

I don't blame athletics and sports for causing eating disorders. Yet often the people who excel at sports, people who can push themselves to practice for hours and days and years at a time, are the ones most temperamentally at risk for developing an eating disorder. I would guess that many elite athletes are perfectionists, and to some extent that perfectionism has served them well. They are at the top of their sport. But this same perfectionism can also embody a tremendous fear of failure- it's often what motivates me. And if someone told me that losing weight would have given me better grades, you better believe I would have starved with the best of 'em.

Competitive anything can be a breeding ground for eating disorders, and sports where weight is judged or otherwise conflated with winning simply adds to the pressure. Most people competing at the Olympics probably don't have a clinical eating disorder, but many probably have disordered eating.

I'm not anti-sports, but the almost overwhelming pressure to win and perform makes me too sad to watch such an event. I would love to celebrate all of the hard work that people have put in, the amazing feats of the human body, the beauty of both raw athletic power and artistic grace. What these athletes have done is amazing, full-stop. But when I think of the cost it must of extracted from some of them, I can't help but feel sad. I know what that's like, that compulsion to compete and perform even though you're no longer certain you even like what you're doing, let alone love it. But without that activity, what else would you have? I was always too scared to find out.

And that's why I won't be watching the Olympics.

I recently read a blog post by Harriet Lerner about anxiety-driven mantras. In the post, Lerner talks about how certain thoughts run through our brains over and over again, usually having to do with being mistreated. These thoughts suck up tremendous time and energy and get us absolutely nowhere.

But Lerner's definition of an "anxiety-driven mantra" was different than what I expected. I immediately thought of an anxiety-driven mantra as the fear that's at the root of all of my angst-ridden ruminations. For me, that fear is pretty simple. My anxiety-driven mantra is this: I'm a failure.

It's what I fear most.

I realize that fear of failure is fairly common, and, to some extent, at least a little bit understandable. My problem is how I define "failure." My definition can be summarized as "anything less than perfect." And since nothing is really perfect, I'm pretty well f*cked in that respect. Even as I am praised by friends and family for writing a book/tweaking a recipe/tying my shoes, I feel like a failure inside because inevitably, it wasn't perfect. The anxiety leaps in here, because I fear that it's just a matter of time until my innate failure becomes obvious.

Hence the never-ending feelings that I'm a fake and a fraud, and the all-consuming fear that one mistake will mean everyone will find out they've been fooled.

The more I think about it, the more I realize that this mantra is also linked to my eating disorder. Gaining weight would make me a "failure." I would have "failed" not only at anorexia, but it would mark me as someone who was weak-willed, and that would make me a failure. Our culture's idea that losing weight is always superior to gaining certainly played a role, but rarely did I fear that others would think I was a failure for gaining weight. I knew pretty much everyone would think that gaining weight would improve my appearance. But it was my own personal standards against which I would judge myself a failure.

And here, too, the AN was a way of telling myself that even if the rest of my life goes to pot, at least I can do one thing right. My not eating made me feel better both in terms of anxiety and depression, and it provided a reassurance (however flimsy) that as long as I was undereating and overexercising, then things would be okay. I would not be a Total Failure^TM.

This is irrational. I'm aware of that. But it's how I've always thought. This is how my standards have always been, despite reassurances from friends and family that a B really was okay and not the end of the world. But it was, I insisted. Where will a B end?

So that's my anxiety-driven mantra: a fear of failure and a desperate need to avoid it. What's yours?

I need your help, everyone, especially if you know a set of twins with anorexia nervosa. The insights of twins are needed in the upcoming textbook Opening the Door on Eating Disorders. From project editor June Alexander:


Twins who have suffered Anorexia Nervosa, or carers of twins who have suffered Anorexia Nervosa, are invited to share their experience in a new international textbook aimed at educating primary care health practitioners and carers. The book, co-authored by June Alexander and Professor Janet Treasure, will be published by Routledge (UK) in 2011. If you fit the above criteria, and are willing to share your story, please contact June who will arrange to collect your story via email, Skype or phone. Anonymity is assured unless specifically stated. Write to June Alexander at june@junealexander.com
For more details about June go to www.junealexander.com

If you have any questions, please feel free to contact myself (carrie@edbites.com) or June.

The draft criteria for eating disorders in the upcoming (and much discussed) revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) have been published this morning. The two most important changes are the listing of Binge Eating Disorder as a stand-alone diagnosis and the removal of the amenorrhea criteria for anorexia nervosa. There were other, more subtle changes that I will discuss in their own blog post a little later.

You can click here for the eating disorders section of the DSM draft criteria.

Here are the diagnosis as listed in the draft version:

Anorexia Nervosa

A. Restriction of food intake relative to caloric requirements leading to the maintenance of a body weight less than a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

B. Intense fear of gaining weight or becoming fat, even though underweight, or persistent behavior to avoid weight gain, even though underweight.

C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Specify current type:

Restricting Type: during the last three months, the person has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Binge-Eating/Purging Type: during the last three months, the person has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

(2) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, or diuretics.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Eating Disorder Not Otherwise Specified

(These aren't actual diagnostic criteria, just a discussion of the issues around EDNOS and how it might change based on other changes in ED diagnostic criteria.)

It is recommended that Binge Eating Disorder, described in this section of DSM-IV, be recognized as an independent disorder in DSM-5. Recommended changes in the criteria for Anorexia Nervosa, Bulimia Nervosa, and for eating and feeding disorders usually beginning in childhood should also reduce the need for Eating Disorder Not Otherwise Specified.

The work group is considering whether it may be useful and appropriate to describe other eating problems (such as purging disorder--recurrent purging in the absence of binge eating, and night eating syndrome) as conditions that may be the focus of clinical attention. Measures of severity would be required, and these conditions might be listed in an Appendix of DSM-5.

If these recommendations are accepted, the examples in Eating Disorder Not Otherwise Specified will be changed accordingly.

Binge Eating Disorder

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. The binge-eating episodes are associated with three (or more) of the following:

1. eating much more rapidly than normal

2. eating until feeling uncomfortably full

3. eating large amounts of food when not feeling physically hungry

4. eating alone because of being embarrassed by how much one is eating

5. feeling disgusted with oneself, depressed, or very guilty after overeatingC. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least once a week for three months.

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (i.e., purging) and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa