Ah yes. Identifying triggers. When I was deep in the eating disorder, pretty much everything triggered eating disordered thinking. Even in early recovery, much of that persisted. A glance at a magazine could trigger a storm of self-loathing. The barest hint of reproach from another person could send me spiraling. And any anxiety-provoking situation would leave me fantasizing about slashing my food intake and increasing my exercise.

Things have improved since then, but there are still any number of situations that amplify the eating disordered thinking and make me ever more vulnerable to relapse. Some of the point of identifying your triggers is to anticipate when you might need extra support. The other point of this is to make what I like to call a "mitigation plan" (it's a term I used when I was working in emergency preparedness, a career move that gave me many ideas into relapse prevention planning) so that you can survive the situation with as little lasting damage as possible.

Here is a (partial) list of my triggers:

• physical illness that affects eating/appetite
• seeing people running/exercising
• moving
• learning of a friend's relapse or weight loss
• weight gain
• new job
• feeling like I don't measure up
• clothes shopping
• getting off my schedule (ie, traveling)
• increase in depression
• increase in anxiety
• financial stress

Some of these triggers can be avoided, many of them cannot. Similarly, some of these triggers can be anticipated, but many cannot. Given that we can't avoid these triggers and we can't anticipate them, what else can we do? Like I did when I worked in emergency preparedness, I had to develop a plan (the mitigation plan) to help deal with them.

I created a general "mitigation plan" for all of my triggers and made certain additions as necessary to fit each particular situation.

My trigger mitigation plan looks like this:

• utilize support system
• increase frequency of therapy appointments
• compare and despair: I am doing the best I can at the moment
• stay to my specific schedule of meals and snacks no matter what
• BE HONEST about urges
• relapse is always there for me- I don't need to act on my urges right this second. I can wait and use my wise mind to think it through, and solicit feedback from others
• distance myself from negative people
• schedule meals and activities with others
• my exercise and eating plan are right FOR ME; it doesn't matter what other people are doing
• relapse only means more clothes shopping so don't go there

Some of these plans are appropriate in a wide variety of situations while others are more specific to certain triggers. The idea is to have a plan that is flexible and can be adapted to a variety of situations but still provide enough guidance on what needs to be done when the going gets tough.

Knowledge is power, they say, and in the case of relapse prevention this is definitely true. The phrase "forewarned is forearmed" is certainly apropos. If, for example, you can anticipate a trigger (maybe having to meet with a difficult family member) then you can start using your mitigation plan even before all hell breaks loose. Even if you can't totally prevent hell from breaking loose, at least you can contain the damage.

I'm starting this relapse prevention series by going back to the (very) basics. One of the major points of relapse prevention is to anticipate some of the difficulties you might have and create a plan for how to deal with them so that they don't trip you up too much. I think there's another aspect of relapse prevention planning that doesn't seem to get as much attention: assessing your strengths. What can you call upon when the going gets tough and the recovery gets tougher?

Together these strengths and weaknesses will provide a framwork for your relapse prevention plan.

Here is the list I wrote for myself:

Strengths

• good support system
• good treatment team
• good insight
• motivation to get/stay better
• can draw upon a wide range of skills

Difficulties

• body dysmorphia
• loneliness
• anxiety
• perfectionism
• putting insight into action
• dealing with change

After I made these lists, I then took each one of these difficulties and made a specific list of how to deal with these issues without using the eating disorder. I'll share the list I made for dealing with body dysmorphia, so I have something concrete to turn to when I have a "fat attack."

Plan for body dysmorphia

• focus on what my body can do rather than what it looks like
• participate in sports or dance vs. all solitary exercising
• repeat mantras: My body is healthy and healing at this weight.
• continue CBT work on addressing body dysmorphia
• "objects in mirror are smaller than they appear"
• talk/share my feelings on body dysmorphia and what else is going on
• accept the fact that I still have body dysmorphia and move on
• remind myself: Losing weight won't solve anything. The ED is a short-term solution to a long-term problem

This list isn't going to be the be-all and end-all for dealing with body dysmorphia and relapse--the issue is a pretty major one for me and this list doesn't even come near to covering it all--but it's a start.

Tomorrow, I'll look at another aspect of relapse prevention: Identifying Triggers

I've been working with TNT on developing my own personal, handy-dandy relapse prevention plan. It's far from the first plan that I've worked on, but it's the first detailed plan that I've worked on.

I've gotten emails and feedback on my blog about the need for better relapse prevention planning, and so I thought I would turn my therapy homework and your requests into a blog series on relapse prevention.

I have some idea of what I want to cover, but I also want input from you to see what issues you would like to see covered. It can be mundane--often the things that trip us up are pretty mundane. I can't guarantee that I will cover everything, but I will do my best.

Stay tuned for the first post later today!

After a two-week hiatus, the Sunday Smorgasbord is back! I hope you enjoy this week's highlights of news, research, and other tasty odds and ends from around the eating disorder world.

Will 'Huge' TV show inspire real-life obese teens? (Why not inspire "obese" teens to feel good about themselves and live their lives at any weight instead of "inspiring" them to lose weight?)

Computer Program Can Detect Depression in Bloggers' texts

Automatic vs. Manual by Lola Snow

Are we expecting the improbable from our patients? Five Part video series from VITA eating disorders program. Part One, Part Two, Part Three, Part Four, Part Five.(Disclaimer: I have not watched these videos in full, but the bits I saw were interesting)

Rethinking the "disease model" of addiction

A Birthday to Remember: Beating Eating and Exercise Disorders

Mental Nurse's latest on the regulation of psychotherapy (This post is part of an ongoing thought-provoking series of posts on the regulation of psychotherapy)

Higher pre-meal anxiety associated with lower food intake in people with anorexia. In other news, the sky is blue and the grass is green.

Want To Be Happier? Avoid False Choices

Evaluation of a functional treatment for binge eating associated with bulimia nervosa

The Switches That Can Turn Mental Illness On and Off

Adolescent girls with subclinical eating disorders more likely to have depression and anxiety disorders

e-Ana and e-Mia: A Content Analysis of Pro-Eating Disorder Web Sites

No, I'm not talking about my own relapse. I'm talking about my cat's.

I picked up my cat from boarding at the vet's for the past two and a half weeks, and I was over the moon to get her back. Aria and I are rarely separated, and it was nice to have my best friend by my side again. When I got her home, I let her out of her carrier and picked her up. I saw her leg and my heart sank. Aria has an autoimmune skin condition that makes her leg itch, and she bites at it until the fur is gone and her leg is raw and bleeding. She's on a low dose of steroids to help keep it under control (I tried numerous alterations in her diet, to no avail) and it has been for quite some time. Not right now, though. It flared up again at the vet's.

Assuming they gave her the medication properly, I can understand that Aria was stressed, and the stress can lead to a flare-up. Even if they did everything properly--even if--how did they miss the fact that so much of her leg was raw and weepy? I picked her up and it was the first thing I noticed. Did they not check on her properly?

I called the vet's office and spoke with someone who assured me that Aria's medication was given properly, but they couldn't explain how someone failed to notice that her condition had gotten worse. I wanted to throttle them. This wasn't just any cat--this was my baby! How could they have let this happen? She had been doing so well when she was home with me, and then she leaves and all hell breaks loose.

Somewhere around this point, when I am simultaneously heartbroken and livid, I realize that this must be a bit what it is like to watch someone struggle with an eating disorder. It must have been baffling to my mother how so many people missed spotting my eating disorder when I was sick. It was right in front of them, under their noses and rather obvious, and yet as my illness got worse, everyone claimed to be caught off guard. And then to have had your loved one do so well while at home and safe, and the second your head is turned, bam!

I also better understand the impulse my mom had to bring me home and help me get well. It's not pathological and over-controlling, it's the response of someone who loves their kid and desperately wants them well. That's what Mommies do.

Aria is (hopefully) on the mend. Her injury doesn't look as red and sore, so I think she's stopped biting at it. Now we just need to let her leg heal and find her another vet--one who isn't negligent.

I blogged yesterday about Part One of Linda Hill's talk on The Noisy Brain, and, as I promised, here is Part Two of her talk from the 2010 International Conference on Eating Disorders. In the second half of her talk, Dr. Hill talked about the need for structure in AN recovery, specifically with respect to meal planning.

In the world of eating disorder recovery, Intuitive Eating is pretty much the holy grail of recovery. It's not a bad ideal, but eating when you're hungry and stopping when you're full can really only work effectively if your hunger and fullness cues are fully operational. In people with eating disorders, especially in early recovery, this really isn't true. At my last residential treatment center, we were taught Intuitive Eating (which wasn't a bad thing), but then we were also expected to be able to put this into action even as we were still in the beginning phases of normalizing eating patterns. Some people found this effective; I didn't. I failed at it miserably, and I had always blamed myself. Perhaps I didn't want recovery enough. Or maybe I wasn't good enough at fighting the ED voice.

You can imagine what a relief it was for me to learn that although the concept of Intuitive Eating is very useful, I can't rely totally on hunger and fullness cues to nourish myself. I definitely couldn't early in my recovery, and I still can't quite totally rely on them now. Instead, I need more structure to help me eat properly, and it's not a matter of personal failure but more of a matter of the very issue that made me so vulnerable to anorexia.

Dr. Hill talked about the need for structure in meal planning as it relates to difficulties in decision-making in people with eating disorders. Here's a segment of what she said (I inserted the links to help define some of the more technical terms):

Automatic emotional reactions don't seem to fire well because the insula is blunted. People with anorexia doesn't appear to have a free-flow ability [to move between emotional aspects of decision-making and evaluating long-term consequences]. Their planning ability seems to be firing overly well.

The AN/BN brain is impaired in identifying the emotional significance of stimuli, but it has an increased ability concerned with planning and executing tasks. There is an emotional blindness to decisions. If there is little or no internal regulation to help the person in decision making, it's easier not to decide. I need few to no options to help me in those decisions. [For people in recovery from anorexia], we need to increase structure and limit options for decisions. To compensate for inability to know what to do, the anorexic turns outward to social cues for rules and answers and to experience reward. In EDs, we begin with a meal plan, and then dose food level to match energy level. We take choice out of it.

So instead of saying "What kind of grain do you want with dinner?" it's more useful to ask "Did you want rice or pasta?" The first option is so open-ended and provokes so much anxiety that it's simply easier to skip that carbohydrate. The number of decisions I have to make when figuring out what to eat can be so overwhelming that I have to find ways to make it easier for myself. In my meal planning post, I wrote about how I have managed to work enough variability into my meal plan while simultaneously keeping the number of choices from getting overwhelming. My solution is the mix-n-match method (or what my dietitian jokingly refers to as the Deal-a-Meal) that keeps me from getting in an anorexic rut, fulfills my necessary exchanges, and allows for enough flexibility that I can go to a restaurant.

The balancing act can be rather precarious, and I think the eventual goal is to move off of a formal meal plan and into a more Intuitive Eating pattern. But the idea is that we use meal planning to shore up those areas in which we might have difficulties and let our strengths speak for themselves.

My brain is rather noisy- there's a cacophony of chatter always going on between that crack team of me, myself, and I. And here's the thing: this chatter never shuts up. Never. If I'm not fretting about something, then I'm trying to anticipate what I might need to do later, the order in which I need to run errands in order to use the least amount of gas, or just daydreaming about something or other. There is never any silence.

Starving myself didn't necessarily stop the chatter, although it did turn the volume down, especially on the self-loathing thoughts. Because as long as I was restricting and over-exercising, at least I could do something right. One of the many reasons that I found it so difficult to start eating on my own again was the fact that eating cranked the volume up on my ED-phones, and I really missed the (relative) peace that came when I was following my strictly limited diet.

At the 2010 Salzburg International Conference on Eating Disorders, Laura Hill from the Center for Balanced Living spoke at length about how recovery from an eating disorder makes the brain "noisier." This noise--this constant cacophony--drowns out almost every shred of sanity that remains.

Said Hill:

Silence doesn't come to anorexia patients if they're eating. When a person without AN eats, brain is relatively quiet. When a person with AN eats, they experience high anxiety, thought disturbance, and "noise." The noisy AN brain [has] layers of noise. The longer [they] delay eating, the lower the noise gets. Recovery doesn't mean that the noise goes away, it means you understand it and manage it better.

To some extent, you get used to the noise.

Ironicially, Hill said that the noise is at its worst just as you reach a healthy weight--something I can attest to rather well. I asked her what happened to the noise level as you maintain a healthy weight in spite of your brain shrieking that "YOU ARE A FAT F*CKING PIG!!!" I wanted to know (for my own selfish sanity!) whether the noise dropped.

Yes, she said. It did.

This one thing--the gap between when your body reaches a healthy weight and your brain begins to follow--is the most difficult, annoying, and frustrating thing in recovery. For all intents and purposes, you look well. You're eating. You don't cry in restaurants and dressing rooms (at least not every single time). But your brain is still deeply anorexic. This is when despair can take over. The noise is worse than ever and yet everyone thinks you're "fine."

At least when I was visibly sick, I thought, people knew I was suffering.

The noise goes down. This is what I've been telling myself. The noise goes down and I will adjust to eating and being at a higher weight than I've ever been and life will go on.

(Laura Hill's talk was so good, I have another segment for a blog post tomorrow!)

Writing the post "The Myth of Motivation" got me wondering:

What is your motivation for recovery?

If you're not currently motivated for recovery, what is standing in your way?

This will help me with a writing project I'm working on, so please share any and all of your thoughts!

You can also share in the "Discussion" section of the ED Bites Facebook page.

I was checking out the plates on FEAST's 2010 Plate Drive (there's still time to create a plate if you haven't yet!) and I got the shock of my life: someone had dedicated a plate to me!

You can check it out by clicking on the Plate Drive link, and it's the fourth row down on the very left.

Whoever you are, you made me cry--in a good way. I am beyond touched. This blog means so much to me, and to have the outside acknowledgement (completely unsolicited!) that it means a lot to others is tremendously touching.

Thank you!

Such was the title of the talk given at the 2010 International Conference on Eating Disorders by British clinician Glenn Waller. Dr. Waller had a fascinating talk and, even when I didn't agree with him, I always thought he had a really good point.

In his talk, Dr. Waller looked at the difficult issue of patient motivation in eating disorders. It's a thorny and fascinating issue to many in the field because people with eating disorders often struggle with staying motivated for treatment. This is inherent to the nature of eating disorders: the denial of a problem (or the inability to see that there is a problem). It's one of the reasons eating disorders are so damned hard to treat.

When my illness first started picking up speed in college, I seriously had no clue that there was anything wrong. I was exercising more! I was losing weight! I felt great! What could be wrong? How could this be an illness? Easy: when you're not eating because you're scared of food, and you're health is starting to suffer. Ultimately, the downsides of an eating disorder become more apparent, and the idea is for a therapist to use these downsides to help patients make behavioral change.

The problem is that motivation is often, as Dr. Waller calls it, a manifesto statement: it's what we want to do, rather than what we intend to do (or are capable of doing). He compared these motivation-oriented statements to campaign promises--they don't really mean much until they're followed by action. This follow-through is where people with eating disorders really struggle, much like politicians.

Dr. Waller's response to this was rather eye-opening. He told therapists to stop being a part of the problem in maintaining poor motivation for change by buying into the motivation manifesto. By doing this, the therapist is trusting the anorexia, not the patient. "The anorexia can only be trusted to try to survive," Dr. Waller said, and motivation to attend/be in treatment doesn't equal motivation to change.

The main factor for me was anxiety and fear about changing my behaviors. I was often tired of the eating disorder but unable to push through the anxiety that was keeping my ritualistic behaviors in place. Thus the status quo remained in place. My other issue was that this fear was coupled by my minimizing the issues that my AN behaviors created. They weren't that bad, I could handle it, most people were on a diet- how was my life different? So how could I be motivated to work on a problem that I often wasn't even sure I had?

Researchers often talk about issues related to patient drop-out and premature treatment termination in people with eating disorders. What astounds me is not so much how many people drop out but how and why so many people stick with it. Dr. Waller didn't really address the issue of outside support, and I wish he would have. I found that I couldn't conquer my ED without someone temporarily stepping in and helping me start eating and gaining weight. I needed to have no other option but recovery--and then I was able to slowly start stepping up to the (dinner) plate and taking charge of my recovery.

The issue of motivation is still very relevant to me, even though I'm rather far along in recovery. Dr. Waller said that motivation work needs to continue throughout therapy as a person can be motivated to address certain issues and not others. Furthermore, motivation can wane or disappear entirely, so it's not something that can be addressed in the first session and then checked off.

There were lots of other bits of Dr. Waller's talk that I didn't agree with, such as his belief that patients who don't change are choosing to stay ill. It often looks like that, but the situation is more complicated. Many times, it wasn't as much that I was choosing to stay ill as much as it was that I didn't have adequate support to change. Yet I'm glad Dr. Waller addressed the issue of motivation, and how therapists can better help people move towards ongoing recovery.

This third post in my 2010 ICED Conference series also has to do with Dr. Kelly Vitousek's keynote address (which is also the source for my AN and Competitive Scrabble post). The title of her talk was "Coming Together Without Losing Our Way," and the best succinct summary I can give of her talk was: controversial. Although I don't personally like controversy (can't everyone just play nice and get along?), it can also be useful because it forces people to clarify their thoughts and positions on certain subjects. Dr. Vitousek's talk did that for me.

Much of Dr. Vitousek's talk focused on the difficulties with identifying eating disorders (specifically anorexia) as brain diseases. Her first point was, in my opinion, a fantastic one: what do we mean when we say "brain disease"? Are we all referring to the same thing?

After hearing Dr. Vitousek speak, I can assure you that we're not.

Dr. Vitousek said that there are three main arenas in which people talk about "brain disease" related to anorexia (the commentary underneath each point is quoted from Dr. Vitousek's talk- I can't promise that every word is exactly as she spoke since I was taking notes via typing and not recording, but it's pretty accurate):

1) The acute brain disorder brought on by semi-starvation

However, starvation brain disorder isn't anorexia, and a person can have severe starvation but not AN. It could be that anorexia causes the brain disorder, but semi-starvation itself isn't a brain disorder.

2) The temperamental traits linked to anorexia, but still not anorexia.

Except that traits are not brain diseases, they're not specific to AN, not uniform in AN, and not essential for AN. They are also not all bad, and they're not going away. Some traits may be tweaked or worked around or invested elsewhere. We think that people are "less to blame" if their brains are at fault. (This next is a direct quote that Dr. Vitousek said should be on a bumper sticker). "Traits don't kill people. AN kills people." It's where traits are put that's the most serious problem. Some traits that help keep EDs running can be drafted to work towards recovery. Increasingly experts who study these issues underscore the powerful potential of these traits.

3) It's some variant on a more specific model of AN brain disorder. Hard wired appetitive dysregulation? Anomalous response to starvation? Problems perceiving body size and shape? Cluster of disordered beliefs?

In my own thinking, option #3 seems to make the most sense. Starvation isn't a brain disorder (though it can trigger one if you have the genetic predisposition to anorexia), nor are the temperamental traits linked to anorexia. These traits can be tremendously adaptive, as Dr. Vitousek pointed out. I think these traits can be markers for having a predisposition to anorexia, but that's far from saying "Here's what anorexia is." Frankly, I think the brain disorder called anorexia is a combination of all of the aspects of option #3. My reading of Dr. Walt Kaye's research on interoceptive awareness (and I will talk more about interoceptive awareness from another ICED talk by Bryan Lask) seems to indicate that this could be one of the lynchpin features of anorexia.

After making these three points, Dr. Vitousek began to deconstruct the use and meaning of the word "brain disorder" with respect to anorexia.

[The use of the term] Brain disorder somehow makes patients' suffering is more "respectable" and more sympathetic if symptoms are seen as wholly beyond their control. Neuroimaging has offered some great PR of learning models and psychotherapy. There have been changes in brain scans due to psychotherapy in anxiety disorders. Treatments for EDs can be psychological even when we use a brain disorder model.

What I'm uncertain of is where Dr. Vitousek got the idea that the brain disease model means that psychotherapies for eating disorders are useless. All the evidence shows that they're very much not useless. Secondly, we shouldn't use the term brain disorder because it's less stigmatizing and gives patients that warm fuzzy feeling. I use the term because I think it's the most accurate description for what is actually happening in anorexia nervosa. Is the fact that it helps us waste less time on the Blame Game an advantage? Yep. But that doesn't have any effect on how accurate or true the brain disease model is. Some people respond to the brain disease model with a "screw it" attitude, because if it's biology, then they're well and truly screwed. Is that a disadvantage to the model? Yep. But that's not a problem with the model, it's a problem with how we are interpreting it.

Nor by saying that eating disorders are brain disorders am I trying to erase the influence of environmental factors, both the larger cultural factors at play and the individual life events that work to increase or decrease our risk for developing an eating disorder. Some of us are at higher risk than others for developing an eating disorder, and there is no doubt that environment plays a role. But I also firmly believe that biology is a HUGE predisposing factor to determining our risk for developing an eating disorder.

Dr. Vitousek then went on to critisize science as a tool for learning more about eating disorders--specifically neuroimaging--and how to treat them. I didn't take too many notes on this particular segment because I was too busy personally seething. Neuroimaging is a new field, and it looks a rather lot like a bunch of pretty pictures of brains. The subject is usually covered in the media along the lines of "such-and-such made the brains light up!" Which isn't accurate- our brains (sadly) don't glow. Neuroimaging studies determine the rate at which certain areas of the brain use oxygen, which is a proxy for their metabolic activity. High oxygen use means high metabolic activity means lots of neurons firing. The levels of oxygen use are color-coded, hence the pretty pictures.

Dr. Vitousek rightly pointed out that people are unduly swayed by pretty pictures of brains. Again, this is a problem with how we interpret these studies rather than an inherent problem with the studies themselves. And there are certainly other problems that neuroimaging studies have, such as small sample sizes and the fact that the scans aren't as sensitive as we would like them to be. Much of the time in eating disorder research, however, the neuroimaging studies have simply confirmed what we already suspected, only now we had actual hard data rather than a hunch or information from a few little mousies.

Should we rely solely on neuroimaging studies to teach us more about eating disorders? Nope, and not even Walt Kaye (Dr. Anorexia Neuroimage himself) would say so. Nor is science the only way of learning more about eating disorders. But it does provide the clearest path forward.

This next post in my summary of the 2010 International Conference on Eating Disorders, in which I'm taking you back to the opening keynote talk by Kelly Vitousek of the University of Hawaii. I could blog for days on the full talk, but instead I will focus on the uber-thought-provoking parts. I'm starting these several posts with a subject rather closely related to yesterday's "Oh, sod it!" post.

In her talk, Dr. Vitousek pointed out the similarities between eating disorders and other extreme behaviors, like competitive birding, extreme mountaineering, even competitive Scrabble. Dr. Vitousek said,

"Anything that many humans value, some will vastly overdo. Can these comparisons help us understand aspects of anorexia we've found persistently obscure by making them more accessible and understandable?"

I love metaphors, and I do think that these comparisons can help people better understand some of the bizarre and baffling behaviors that go along with eating disorders. Both eating disorders and extreme behaviors involve obsessive behaviors that the person often embraces and even seeks out. These behaviors--whether eating disordered or not--ultimately form a large part of the person's identity and sense of self. Often, a thriving subculture develops around people who engage in these behaviors. And I think both people with eating disorders and those competitive birders and the like have trouble saying "Oh, sod it!"

The problem with using such comparisons is the wide gulf of impact that exists between competitive Scrabble players and those with eating disorders. Sure, your life can revolve around competitive Scrabble to the detriment of personal and professional relationships, but it likely won't kill you. And although extreme mountaineering can be deadly, participants often know what they're getting themselves into; as well, the issue of choice is much higher than in eating disorders (i.e., eating disorders are frequently anosognostic; mountaineering isn't).

I think we also need to be careful about saying "Wow, there are a lot of similarities between eating disorders and these other extreme behaviors" rather than "An eating disorder is just like competitive Scrabble." Because that's just not true. I know that Dr. Vitousek didn't imply this, but I'm also well aware of how media can mangle things. The comparisons aren't meant as a dismissal or minimization, but rather a different way of looking at eating disorders.

My other issue is with Dr. Vitousek's "overvaluation" comment. Granted, part of the diagnostic criteria for anorexia and bulimia is an overvaluation of weight and shape, and I certainly wouldn't deny that this is a large feature of EDs for many people. However, there is a big difference between shape/weight overvaluation being a feature of an eating disorder and that being the root issue of an eating disorder. Research has shown that the desire to stay underweight seen in some people with AN isn't an overvaluation of thinness as much as it is a phobia about getting fat. This is not to say that our culture's overvaluation of the Thin Ideal is irrelevant to eating disorders, but that doesn't appear to be what's going on in the brains of people with anorexia.

It has helped me to reframe my own body dysmorphia as a phobia of gaining weight rather than silly little Carrie wanting to look like a supermodel. Because that wasn't really what my thinking was like. It helps me to reframe the issue with my OCD: my cleaning rituals weren't an "overvaluation" of cleanliness, but a way to reduce the anxiety that came with not cleaning. For me, then, weight loss was as much about relieving the anxiety about gaining weight as it was about "looking" a particular way. I had similar anxieties about eating too much or not exercising enough, and so I've slowly started to reframe this behaviors as compulsions rather than a simple desire to eat right that just got out of hand. I still have the desire to maintain a healthy diet now that I'm in recovery, and although I probably think a lot more about it than most people, it doesn't always rule my life.

Eating disorders don't exist just because our culture overvalues thinness. We wouldn't say that mania exists because our culture overvalues happiness. Or that schizophrenia exists because our culture overvalues a rich, inner dialogue. Certainly people with eating disorders can be prone to overvaluing something, but there's a difference between that and saying that eating disorders are an overvaluation of something.

Still, I think the comparison was rather interesting, and it can provide some new ways of thinking about eating disorders.

Now that my brain has begun adjusting to European time, I'm going to begin a series of blog posts that digest and explore many of the interesting talks I heard while in Salzburg.

In one of the introductions to this year's award winners, the winner was mentioned as having said (rather tongue in cheek) that the main cause of anorexia was the lack of the "Oh, sod it!" gene. I laughed, of course, but the more I thought about it, the more I realized that there probably was something to that.

Long before the AN showed up in my life, I had trouble knowing when to stop. I remember studying many times in high school, as I was falling down exhausted and swilling countless cups of coffee, thinking "I need to study some more." I was aware on some level, that I knew the material pretty well, at least well enough to get an A-, but that wasn't good enough. The thought of anything less than knowing every single answer (and then some!) caused this terrible anxiety that would kick in with the mantra I need to study more.

As the clock ticked later and later on these nights, I often wished that I could let myself go to bed. I desperately wanted to stop caring about every last answer to every last question (or the placement of every last comma on term papers), but I just couldn't do it. I literally didn't have the ability to say "Oh, sod it!" and get some rest. It really didn't occur to me as a valid option.

This, of course, meant good grades and scholarly success, so it wasn't all bad. But this extreme studying was a harbinger for the eating disorder. Even as I started to recognize that self-starvation was killing me, I couldn't say "Oh, sod it!" and pick up a fork. I couldn't say I'd lost enough weight or exercised for enough hours or eaten few enough calories--I couldn't ever feel "good enough." When you combine that never-good-enough feeling with an intense, obsessive drive to achieve a goal, you have the mental disaster that can result in OCD, anorexia, and just obsessive behavior.

I still struggle with learning when to say "Oh, sod it!" and just go to bed or focus on something new. I have gotten better in honoring exhaustion-laden apathy (as in "I don't care, I just want to sleep") but my behaviors are still probably fairly extreme. I've started blogging many times, knowing full well I'm exhausted and need sleep, but feeling compelled to write anyway. Much of my struggle has lessened when I realize that I'm not ever going to naturally say "Oh, sod it!" very often unless under duress. So I need to practice this: practice accepting less than the best, practice listening to my body's cues for food and rest, practice throwing in the towel before I drop over. It's a skill, a skill like many others.

I was going to add something else to this post, but what better time to say sod it, right?

The death of any young person is almost invariably a tragedy. But when I heard of Erin's death from anorexia, the tragedy seemed much worse. Not because of the specific cause of death (an eating disorder) but because her death was completely unnecessary.

I've only heard the tip of the iceberg when it comes to this family's suffering for almost 20 years, and it is already almost unimaginable. Even the diagnosis of anorexia can be tragic, but when the system colludes with the eating disorder and gives the family and sufferer the finger, well, that just adds insult to injury.

Yes, some cases of anorexia are harder to treat than others, and Erin's wasn't an easy case. But some cancers are more difficult to treat, and we don't sit around and ask the tumor why it doesn't want to stop growing. Cancer cells keep dividing; that's the nature of the beast, and we don't blame the damn cells, we just do everything we can to keep them from dividing. So why is it that people with eating disorders are fundamentally expected to want and embrace recovery when everything in their brains is telling them to keep starving, bingeing, and purging?

Anosognostic and angry patients aren't easy to treat, and it's all to easy to comply with an anorexic's stated wishes rather than her unstated needs. We all do it- it keeps the peace, allows us to continue in our lives with a minimum of fuss. But an eating disorder can mean that a patient's wishes and desires can become deadly. Patients want to leave treatment prematurely. They want to remain at a low weight. But these are symptoms of the eating disorder rather than true inner desires of the patient. I don't understand why it's so hard to separate these two facts. In Erin's case, the system blatantly didn't separate her eating disorder symptoms from her true needs, and now Erin is gone and there's not a damn thing any of us can do about it.

It's easy to think that at least Erin isn't suffering anymore, that if she couldn't be helped, then it was better this way. Maybe these sentiments are true--I don't know. But as soon as I think this, I want to shake myself in utter frustration. We know how to treat eating disorders. We do. We frequently suck at it, but we know how to treat EDs. Erin didn't have to die. She shouldn't have had to wait to want and embrace recovery before her treatment providers removed every option but recovery. When the prospect of getting better is so exhausting and frightening, and when your brain feels so much better when you are ill, it's no wonder that many sufferers simply find recovery a difficult concept to embrace.

Erin was almost certainly labeled "chronic" and "resistant," which are pretty much key words for "hopeless" and "palliative care." I know I got all of these labels. Talk about depressing and demoralizing--I doubted my own recovery enough. The last thing I needed was someone telling me "I can't help you." What ultimately made the difference for me was not my sudden willingness to gain weight but a therapist who left me with no other option but recovery. By doing this, she was telling me that she believed I could get well.

Erin won't get this chance to get well. Her mother won't get to plan her wedding. Erin's death wasn't a sudden freak occurrence that caught everyone off guard. It was the result of years of illness and years of our health care system's neglecting to properly treat her illness. Her eating disorder killed her, yes, but our fucked up, outdated, and shortsighted medical system played just as large of a role.

When I attend these large eating disorder conferences, it often feels rather surreal. Here I am, little old me, surrounded by (and engaging with!) these internationally renowned professionals. It never ceases to both amaze and astound me that this is really happening.

Tonight was one of those nights. I had dinner and a few beers in a Salzburg beer garden with Laura Collins, June Alexander, Susan Ringwood of B-eat (and her husband), Walt Kaye and Kitty Westin. I'm chatting with each of them, enjoying dinner and talking as if there was nothing more natural in the world than to be sitting here and sharing dinner with these amazing people.

I couldn't have felt more in awe if I had been meeting celebrities- and in the eating disorder world, these people really are celebrities. Laura insisted on reminding me that I was also a bit of a celebrity, although I don't know I will ever think of myself in that fashion.

The conference has been amazing, and I am so glad I came. It's been great to interact with such wonderful and passionate people from around the world. Tomorrow is my last day both at the conference and in Salzburg, and the presentation of my award in the afternoon.

For the time being, though, I need to try and get some rest!

I am having a wonderful time here in Salzburg, and I can't wait to blog about many of the interesting speakers and latest research. However, given the fact that I've slept about 4 hours in the past 3 days, I'm going to wait until I have a little more brain function to deconstruct and build upon what I learned.

I had planned on live Tweeting the conference, but I was disappointed to learn that the conference center didn't have free wireless internet and I couldn't piggyback on any local free signals from hotels or cafes. So I will subsume my happy updates into my longer blog posts on the conference. I apologize as I wish I could have shared the conference with you in real time but I don't know I have enough karma yet.

Instead, I'm going to blog about (of all things) sudoku. It's one of my favorite hobbies and means of relaxing when I get worked up. Despite my being a writer, I'm not much of a crossword fan--in fact, I'm rather terrible at crosswords--but I love sudoku. I bought a purse sized book to bring with me on my trip as my usual book is pretty massive. As I was sitting on the plane and waiting in the Frankfurt Airport, I was working on some puzzles and it suddenly struck me how much working on these puzzles reminded me of recovery. And no, it wasn't just because recovery is so darn puzzling.

Sudoku has certain specific "rules" that guide you in filling in the 9 by 9 square of numbers. Everyone has a different strategy for filling in the numbers within the rules, and each puzzle requires you to pull upon a variety of strategies in order to solve the puzzle. Often, by switching between different tactics, I am able to see the solution much more clearly than if I had just stuck to one way of solving the puzzle.

So it goes with recovery. The rules I see as defining recovery start with physical and nutritional rehabilitation, and also involves an improvement in quality of life, a decrease in other psychological issues, and an improved flexibility around food and eating. These rules are meant less as constraints on what you can do (although if you could write any number in any box, there wouldn't be much point to the game) and more to provide a framework in which to create your recovery.

I have struggled with basically every aspect of recovery, but one of my biggest difficulties has been identifying different strategies to maintain my recovery and then the flexibility to switch between these different approaches as the situation requires. It's similar to my Sudoku solving skills (or even Spider Solitare, which is my other favorite de-stressing game), in that I often get so focused on filling in every last "3" or filling in one particular row or column or square, that I lose sight of the rest of the puzzle. So I get frustrated and give up, or make a really stupid mistake because I lose my ability to rely on logic and reason. This is pretty similar to how I get into trouble with relapse. I struggle with being inflexible (life should be this way not that way and I have difficulties adapting), which leads me to make dumb mistakes (skipping breakfast is no big deal, right?) because I'm not being logical (I've gotten in trouble every other time I've skipped breakfast, and there's no reason to expect that this time would be any different). Or I just chuck the whole recovery idea in the bin and say "Screw it. I'm going back to the restricting because this sucks and I can't get it so what's the point?"

The similarity that especially struck me on my trip was how I have learned to cope with my sudoku frustrations. In the more difficult puzzles, I often reach a point where the puzzle seems unsolvable. I can't seem to make heads or tails of the puzzle and no matter how much I stare at the numbers, none of the solutions seem obvious. I feel completely and utterly stuck, and many times get ready to write off the puzzle.

So it goes with getting stuck in recovery. I can look around and try different strategies and sometimes, there's no getting around the fact that I have no idea what to do. I feel like I'm never going to get anywhere, that recovery will be forever out of my reach.

Yet with my sudoku puzzles, I keep working the game, keep plugging away at it, and often the solution that so stubbornly evaded me becomes clear. The puzzle is by no means solved, but the way forward becomes much clearer.

Another reason I prefer sudoku to crosswords is that it's much easier to discover when you've gone wrong. There is one right answer. I suppose there is one right answer in a crossword, although it's possible to fill in different words and still have a puzzle that looks right but isn't. Sudoku doesn't have that uncertainty.

This is, I suppose, where recovery and sudoku diverge. There isn't one right recovery or one right way to reach recovery. Nor does recovery come with the "Eureka!" moment when you realize you've gotten everything in its place and you're going to be just fine. It's more of a slow unveiling of the solution and how much progress you've made towards your goal.

Protein bars? Check.

Camera? Check.

Passport? Check.

Bank card? Check.

Netbook? Check.

Sudoku book? Check.

Extra underwear? Check.

Benadryl so I can sleep on the plane? Check.

Heels I can barely walk in? Check.

Sense of adventure? Double check.

I will continue to post while I am away (which is why I bought the netbook!), but it will probably be sporadic as I'm not sure when and where I'll have internet access. I intend to tweet from AED, so stay tuned for that (I'll try and post summaries). I'll also blog on the smokin' hot science presented at the conference as I indulge my inner geek. I may also post selected pictures, etc.

My ED is staying stateside (I'm hoping he'll go drown himself in the Atlantic, but he's not an obliging fellow). I'm super excited to see Europe, and thanks for all your support!

This will be your last smorgasbord for a few weeks, folks. I'm going to Europe to the AED conference and then to wander around Germany and Austria (without stressing too much over the food!) Considering that I don't know when/if I'll have internet access in some of these small towns, I don't know that I'll have the time to put together a smorgasbord. So enjoy this edition and I'll be back to my weekly posting when I return.

If you were to eat only foods advertised on TV, you would get more than 20 times the recommended fat and sugar, but less than half of the suggested amounts of vegetables.

Feeling out food: Why we eat the things we do

Anorexia isn't a prestigious illness (as far as research goes)

The tyranny of perfection

10 Life-Enhancing Things You Can Do in Ten Minutes or Less

Laboratory parameters and appetite regulators in patients with anorexia nervosa

Signs you have an eating disorder (and don't know it)

Preliminary evidence for a role for impulsivity in cognitive disinhibition in bulimia nervosa

Impaired identity recognition of faces with emotional expressions in body dysmorphic disorder

FEAST Launches the June 2010 Plate Drive

Associations between body mass index, weight control concerns and behaviors, and eating disorder symptoms among non-clinical Chinese adolescents

A set of prerequisites for not only stopping starving, but starting living again

Lard Lesson: Why Fat Lubricates Your Appetite

30% of visitors to "Proud2BMe" stop visiting pro-ana sites (the press release is in Dutch- you can translate by copying and pasting the URL into Google Translate)

I've never really considered myself athletic. For starters, my coordination and grace are pretty minimal (I was voted "Class Klutz" in high school). Second, sports were never really a big thing in my family. Lastly, I always thought of myself as too chubby to play sports (even though I wasn't). I was almost always chosen last in gym class, which ultimately made sports a humiliating experience that I wrote off as quickly as possible.

I started exercising in college to manage stress, but I never really integrated that into my identity. Then I ultimately gravitated to compulsive exercise as part of the eating disorder. Carrie the Gym Rat was very much a part of my identity, but I still didn't see myself as particularly athletic. The actual exercise was fairly irrelevant--as long as I was burning calories, engaging in the ritual, and mentally checking out while exercising, it didn't matter.

That has changed as I've gotten stronger in my recovery. I've been doing a fair amount of cycling, and I took a Pilates class for a while. I've been thinking about taking a kickboxing class, or an Irish dance class, or even a dance aerobics class (I did it a few years ago and it was pretty fun). I would love to go kayaking and learn how to play tennis. I took tennis lessons when I was about 12 or so, but I quit after I nailed my teacher in the nads with a ball--he did say "Aim it at me!"--and I was too embarrassed to go back because I had a big crush on him. I would love to get back into it.

All of these activities has caused me to rethink the absence of "athletic" from my self-concept. I'm not much into team sports like basketball or volleyball. I'm still not at all coordinated, and since I don't like many quote-unquote "sports" (at least as they're mostly thought of in the US), I don't feel entirely comfortable calling myself athletic. But I have started to think of myself as "sporty." I like being active, even above and beyond the eating disorder. I'm not super-adventurous, but I do like to try new activities, especially water sports.

It's been interesting, this learning to think of myself as a sporty person. And I like it. It feels genuine and authentic, a side of myself I never thought I had.

"Oh, I'm being so bad!"

I can't tell how many times I hear that at the bakery over the course of a day. It's mostly women who say this, although it's not exclusively women. I keep asking myself: how did dessert get defined as bad or sinful or off-limits anyway?

I'm aware that the history is rather complicated, and I've read many books looking at the subject. It all seems to stem from the premise that under-eating is somehow virtuous, and over-eating is a sin. After all, gluttony is one of the Seven Deadly sins, but dieting is nowhere to be seen. I find the religious overtones fascinating, too: desserts as sin and exercise as atonement. It seems these religious sentiments are particularly associated with Christianity (although living in suburban America, Christianity is the dominant religion wherever I've lived). I mean, have you ever seen a fat Jesus?

Yet with all of the evil and wrongs and despair in this world--the oil spill in the Gulf, the wars, the economic difficulties--we most frequently refer to "bad" in context with dessert. It's cake! Eating it doesn't make you a sinner or a saint. It just makes you an eater of cake.

So when yet another women gave me her order ("One cannoli and a red velvet cupcake, please!") and then lamented, "Oh, I'm being so bad!" I looked at her and said the following:

"Ma'am, you said please and you're not stealing anything. How could you be bad?"

She looked at me.
And laughed.
And ruefully admitted: "I guess not."

This next Tuesday, I leave for Austria, Germany, and the 2010 International Conference on Eating Disorders in Salzburg. I've been to the UK twice (even lived there for a semester in college), but I've never been to mainland Europe or any country whose native language isn't English. It's exciting, and it's also a little nerve-wracking. My silly brain comes up with all sorts of scenarios to worry about, such as: what if the volcano in Iceland starts erupting again? What if I have to take a bath rather than a shower (it's a "thing" of mine, baths)? What if I don't know how to order decaf coffee or Diet Coke/Coke Light? What if our luggage gets lost?

There are those "what ifs" that I'm guessing many travelers with anxiety can relate to. Of course, my history of anorexia means I'm also worried about the food. My knee-jerk concern is that I'm going to gain heaps of weight while away. Granted, most German cooking isn't exactly low-calorie, but I also know that I basically have no real tendencies to overeat. Then I worry that the ED might decide to stow away in my luggage and ruin the trip and make me scared of all the food. I'm not sure how I can simultaneously worry about both weight gain and relapse at the same time, but let me assure you that it is possible!

Part of what I've learned in recovery is to always make sure I have food with me in case of emergencies. These so-called emergencies can be anything as minor as I get hungry at a rather inopportune time (high on the Alps, say), to being in a town and not finding anything I like. Most people probably wouldn't fret all that much about these scenarios, but I know I have to anticipate such things to maintain my recovery.

So here's a sampling of what I'm bringing: packets of Carnation Instant Breakfast (to add to milk or coffee to amp up any breakfasts that might be lacking or have at night), instant oatmeal, squeeze packs of almond butter to keep in my purse (no utensils necessary!), protein bars, and a water bottle. I'm very familiar with all of these options, so if I get spooked by massive portions of schnitzel or I find myself in any other bizarre situation, I have something safe and standard to fall back on.

Part of me, of course, wouldn't mind bringing all of my food, but a) I know that's pretty disordered thinking and b) how would I pack my shoes if I had all that food. I am looking forward to being able to try new food and such--it's one of the things I like about traveling--but it the prospect does bring a little uptick in anxiety. Like so many things in life, it's a mixed bag. I can't recover if I'm always hesitating and hanging back and staying perfectly "safe." I need to push the envelope just a bit, so I can have the experience of succeeding at another eating situation.

What are some tips that you use to stay in recovery while traveling?

I'm an avid fan of Facebook and social networking (although I haven't yet succumbed to FarmVille...) and I realized that it's high time ED Bites gets its own fan page.

My question for my readers is: what sort of information would you like to see on the ED Bites page?

On the one hand, I don't want to duplicate what I do here and on Twitter (you do follow me on Twitter, right?). On the other hand, I realize not everyone appreciates Twitter or is able to check my blog every single day. I know I can cross-post from Twitter to Facebook, a feature I intend to take advantage of. My goal at this point in time is to use my Facebook page to expand on my Twitter updates- I am, after all, a writer and that whole express-yourself-in-140-characters-or-less doesn't always work for everything I want to say.

So in the comments, feel free to share what you would like to see, any examples of awesome Facebook fan pages, or other thoughts you might have.

I have the best readers on any blog, ever. No exaggeration. I don't have enough good things to say about all of the support and wisdom I received on my last post.

Thankfully, coworker A wasn't working today so any fantasies about squashing her like a bug (or at least giving her a good bitch slapping) remained fantasies. As my friend Melissa told me, I'm not going to let her rent space in my head. In the end, it's fairly irrelevant what she thinks of me. It doesn't change what I need to do in recovery. I don't think I'm going to bring it up with her because I don't think it's worth it. If it happens again, I definitely will give her a piece of my mind.

Thanks again. You are the best.