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!)

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?