Obsessive-compulsive disorder (OCD) is one of the most frequently diagnosed psychiatric disorders in people with eating disorders. It is known to make eating disorders more severe and harder to treat, leading to a longer time until remission is achieved. Recently, more and more researchers are beginning to recognize the significance of the overlap between EDs and OCD, and are trying to develop specific treatments targeted at this population.

A 2004 study by Walter Kaye and colleagues in the American Journal of Psychiatry measured how frequently anxiety disorders (OCD is a type of anxiety disorder) occurred in people with anorexia and bulimia. They found that two-thirds of the ED sufferers had been diagnosed with an anxiety disorder at some point in their life. In general, the onset of the anxiety disorder pre-dated the ED by several years. Of the people with an anxiety disorder, 41% had OCD and 20% had social phobia (social anxiety). The problem, then, is very significant.

The gold standard in treating OCD is a form of cognitive-behavioral therapy known as exposure and response prevention (ERP). You can read more about ERP here. The idea is relatively straightforward: You create a hierarchy of the things you're afraid of that would normally provoke a compulsion. For someone who is afraid of germs, something lower on the list would be touching an unused surgical mask. Higher up might be touching a doorknob at a doctor's office or being coughed on by someone with a cold. Together with a therapist, you would begin to expose yourself to these anxiety-provoking situations and then not engage in any compulsions (like hand-washing) to relieve the anxiety. The point of this is to learn to tolerate the anxiety and that you're not going to die if you happen to inhale a few germs.

Some researchers are beginning to use components of ERP to treat food fears in EDs, especially anorexia nervosa. In a 2011 study in the International Journal of Eating Disorders, researchers at Columbia University first outline a behavioral model for AN that is driven by anxiety and obsessionality (see figure below; the caption is copied from the paper).

Figure 1. Model of Anorexia Nervosa. Traits of high baseline anxiety and obsessionality interact with environmental factors such that patients develop maladaptive behaviors, including food avoidance, and rigid eating patterns (or dieting practices), and they experience high levels of anxiety around eating. These behaviors are interrelated in that rigid dieting leads to increased anxiety about food and vice versa. These behaviors result in a diet that is low fat (low energy density) and limited in variety. This, in turn, promotes weight loss. The low weight state feeds back on the baseline traits and leads to increased levels of anxiety and obsessionality.

Anxiety about eating more and gaining weight consistently interferes with weight gain in AN and with interrupting the binge/purge cycle in BN. The idea is that recovery cannot and will not occur unless these fears are addressed. In a 2012 review article in the European Eating Disorders Review, psychologists hypothesize that one of the reasons family-based treatment is successful for many adolescents is that it forces these exposures. Since the patients can't (theoretically) choose what to eat, they can't choose to avoid "scary" foods. Parents are also coached on how to help stop other food-related rituals

A study published earlier this week addressed the issue of treating OCD and EDs, this time in a residential setting. Published in Cognitive Behaviour Therapy, the researchers treated 56 individuals with AN, BN, or EDNOS in an eating disorder program specific for individuals with co-occurring OCD. Of these patients, 41% were diagnosed with AN, 25% with BN, and 34% with EDNOS. Rates and levels of depression and OCD did not appear to vary by diagnosis. After treatment, the researchers found a significant improvement on scores for OCD, depression, and eating disorders, as assessed by a variety of surveys and self-reports. Patients with AN also significantly increased their body weight.

Which is all well and good, but the problem is that this study (nor any others that I'm aware of) compared the treatment group to anything. Other studies have shown that treating an ED generally improves levels of depression and OCD. Was the improvement seen in this study due to regular eating and the prevention of binge eating and purging? What effect did being in a structured environment have? Would these results have been different if the patients weren't treated for OCD? What about if their OCD was treated and not their ED? I realize that actually conducting a research study in that last scenario would be unethical, especially in a group that qualifies for residential treatment, but it's something that should at least be considered in the discussion.

Another question the researchers didn't factor in was the use of psychotropic medication. Eighty-nine percent of patients were on some type of psychiatric medication; the authors said they didn't control for this in their analysis since only 7% started on medication during their treatment. But they didn't mention how many patients' medication was adjusted, increasing or decreasing dose, or changing types and brands of medication. These things can have a significant effect on OCD and depression symptoms (although a recent study indicated that no psychotropic medications appear to be effective for AN)

As well, one of the researchers is the medical director of the treatment center where the research was carried out. This makes me a little skeptical of the results as a matter of course.

The researchers concluded that "Simultaneous treatment of OCD and eating disorders using a multimodal approach that emphasizes ERP techniques for both OCD and eating disorders can be an effective treatment strategy for these complex cases." But how effective? Is it better? How much better? How long did the results last for? There was no follow-up on any of these patients. Improving in a program is great, but the rubber doesn't really hit the road until after discharge.

This study is a start, but it's a small start. Co-occurring EDs and OCD can be very difficult to treat, but many people do go on to develop healthy and productive lives. We desperately need more resarch into the subject, but we need to start making comparisons to help develop the best, most effective treatment possible.

I was in the bathroom today, and I got to thinking (thinking, for me, is generally a dangerous phenomenon and especially so when I have lots of time to myself, such as when using the loo).  Alcoholics can take Antabuse.  It doesn't take away the cravings or the ability to drink, it just makes drinking extremely unpleasant.  And I was thinking that it would be nice if I could have something like that for anorexia.  Something to make the illness immediately and acutely unpleasant.  Something to retrain my brain from thinking "But not eating will make me feel so much better..."

Of course, if an alcoholic really wanted to drink, they would just not take the Antabuse, but still.

I know that anorexia does make me feel worse in the long run.  But then I think that not eating will make me feel better right now, and it gets hard.  Because "long term" is very cognitive; "right now" is much more emotional.  It's much harder to use cognitive skills against a very visceral reaction.  It makes good evolutionary sense. When there's real danger, it's actually an asset to act without thinking.  The problem is that our brains generally suck at figuring out when it's real danger (as in OMG-I'm-going-to-be-eaten-by-a-tiger) and when it's not.  Again, thank natural selection.  It operates on whatever helps us survive and reproduce, not what makes our lives calm.

Which brings up the next question: maybe it's not my response (stress=ED thoughts), but my perception of danger.  The problem is that I find the world pretty terrifying.  And what do you do when you always feel on edge?  When you're never quite sure what will come back and bite you in the ass and so you treat everything like a rabid animal?

I think it's something I need to discuss with Dr. H tomorrow.  I know I need to desensitize myself to many of these things.  Exposure and response prevention is very effective with OCD, and I know personally that it's helped diminish my food fears.  But with the OCD and anorexia, I had something concrete to work on.  I was scared of germs.  Or food.  Or of hitting someone with my car.  Now, my problem isn't so much OCD but generalized anxiety, that constant "what if" chattering away in the back of my mind.

Anxiety can be overcome--or at least people can learn to live with it.  I'm still trying to figure out how.

Last night, I had a fat attack.  My old therapist back in Michigan would have preferred that I reframe it as a "bad body image attack."  Well, maybe.  But this feeling was very different than looking in the mirror and saying "Ewwww..."  Which I've also been known to do, but not last night.

For starters, I was laying in bed and not looking in the mirror.

For seconds, it wasn't a visual issue.  It was a more physical, visceral issue. 

I wanted to claw my way out of my own skin.  I felt huge, uncomfortable.  I couldn't stop thinking about my body.  I wanted to do something, anything to get rid of this feeling.

Somewhere through the anxiety, I started thinking, "You know what this reminds me of?"

OCD.

I had the stereotypical germ OCD when I was in high school.  Mostly, I obsessed and worried over every little thing.  Either I was harboring some nasty germ that was going to kill everyone I knew or saw or had contact with, or everyone I knew, saw, or had contact with had a germ that was going to kill me.  I would wash my hands or reply scenes in my mind to make sure I hadn't touched something "bad" or coughed wrong or whatever.  I would inspect every inch of my skin to make sure I didn't have any cuts that could get or receive germs.

Therapists call these contamination fears.

I felt like my skin was crawling with germs.  I washed my cracked, pathetic hands in bleach to try and make this feeling go away.  No, I couldn't see the germs. I wasn't always 100% positive they were there, but I was sure that I could feel them.  All I wanted to do was make that feeling go away.  If it meant screaming in pain from bleach, so be it.  I was so distressed and terrified that nothing else mattered but making this feeling go away.

Which brings me back to the fat attack.

I didn't feel that my skin was crawling with germs, but it did feel like it was crawling with fat cells.  And in moments like that, it suddenly doesn't seem so foreign/stupid/pointless to do something like purge or overexercise.  I didn't, but nonetheless.  Thinking of these fat attacks as another manifestation of my OCD has made a lot of sense to me.  Yes, I have significant body dysmorphia above and beyond the fat attacks. 

Yet any time off exercise or eating something "unsafe" or "forbidden" would bring about a fat attack--just as touching something dirty would set off a contamination attack.

I don't think this totally explains my eating disorder.  Not at all.  But it does explain parts of it.  It helps explain why I would do such crazy things.  To escape the distress.  To keep the calm.  Vanity and sticking to my "diet" wouldn't--couldn't--explain this.  If you're scared enough, you will do some crazy things.

I never was able to recover on my own as an outpatient because the fears and the feelings were just too strong.  It meant living in a non-stop fat attack for months with no sense of relief.  Considering the crazy stunts I pulled to avoid the feeling just for a few hours or days, is it really any wonder that I tried to avoid refeeding and recovery?

Seeing fat attacks as OCD helps me calm down in the moment.  It's just the OCD talking.  The OCD was wrong about me spreading or receiving the plague, so it's certainly wrong about this.  What's more, I know the awful feelings do pass.  Eventually.

I have the Arnold Family Thighs^TM. It makes jeans shopping an absolute nightmare, and let's not even start in on my body image issues.

But I'm not going to bore you all with an entire post about how much I hate my thighs.  I think about it enough.  Instead, I'm going to write about a time this past weekend when I didn't totally hate my thighs.

I've written about my love for my bike and how cycling has really helped in my recovery.  This past weekend, I did a longer ride as part of a group outing to a local national park.  The trip was really, really fun.  I was rather proud of myself that I kept up with the fastest in the group with no problem (except for the one self-proclaimed Speed Demon).  It was a mixture of road and paved and unpaved bike trail.  The weather was perfect, and I had a great time.

While I was riding, though, I wasn't cursing those Arnold Family Thighs^TM.  I was thinking that those thighs--my own damn thighs!--might be one of the reasons I was so good at biking.  Instead of being a liability in jeans and a bathing suit, my thighs were an asset.

I still hate how they look.  I still think they quiver so much when I walk that you could reasonably measure the vibrations on the Richter scale.  Cycling hasn't made me love my thighs, but it has made me appreciate their function.  I'm not going to get all sappy on you and write a long thank you note to my thighs.  That's not the point of this post, nor could I handle that much cheesiness all at once.  The point of this post is learning to appreciate something you don't like, of turning your liabilities into assets.

I've probably mentioned this before, but my OCD habits and behaviors have gotten me a writing job (that I ultimately turned down for other reasons).  My proposal was the only one without any typos, so the person picked me--I don't think I was supposed to see that email, but there you have it.  Most of the time, my OCD is a huge drain on me and the stuff I want to do.  I can't do things because I'm too busy checking and counting and double-checking.  I don't like my OCD stuff.  It annoys the crap out of me.  But as much as it has been a tremendous liability, it has also been an asset.

The liability of my thighs is probably mostly in my head--and in a few screaming hot pairs of jeans I had to leave behind.  But my thighs aren't universally bad or useless.  They help me ride my bike.

I ate lunch at Panera today, and there was something new on the menu: calorie counts.

It didn't mess with my head as badly as this prior experience, nor did it rattle me for very long. It annoyed me and upset me a bit, in no small part because I wasn't expecting it.

The calories were listed on the right-hand side of the menu, next to the price. The description of the food was listed on the left. When I was deep in the ED, I would have picked everything out beforehand if I couldn't weasel my way out of the occasion, so I could make absolutely sure I wasn't eating one single calorie more than I had to. I would have asked for the chips (if my meal came with that--it threw people off my trail) and saved them "for later," neatly disposing of them when no one was looking. Early in recovery, I would have made a minimal attempt to ignore the information, and then have found the lowest calorie item and ordered that. I would have gotten the apple or the carrot sticks as a side dish, but I would, in fact, eat these.

I was able to be much more calm and rational. Instead of finding the item with the lowest calories and then deciding if I would order that (as long as I didn't hate anything integral to the dish), I looked at the different dishes and then checked the calories.

In an ideal world, the calorie information would just be numbers, like the metric tons of methane produced by flatulent bovines. "Party facts," my undergraduate advisor called them. But over a decade of an ED means that facts aren't just facts. They're very emotionally charged facts. They're not just numbers, nor are they going to BE just numbers any time in the near future.

Given that fact, I did the next best thing: I tried to make the (irrelevant) information as small a part of my decision as possible. I did order a yummy entree salad with a hunk o' bread on the side. It fulfilled my meal plan requirements. The number was also within the "acceptable" limits. Was there something else on the menu I might have liked more? Probably. Were the calories a factor? Yep. Were they the only factor? Not really.

The big difference wasn't that I overcame my calorie-counting compulsion* and felt the shackles fall from my ankles. The difference was that I could be much more rational and healthy about my decision-making process. I could focus on what I might want to order AND the calories. Usually the first factor was almost completely ignored. As long as I didn't hate the lowest calorie item, that was what I ordered. I freaked out and all semblance of sanity went out the window. This time, it didn't. This time, I was able to step back for a second, take a deep breath, and do what I needed to do.

*I get obsessive about numbers in general- the OCD and the AN pretty much fed the compulsive counting.

At least, this is what I'm telling myself right now.

It seems to be the cure, because I'm always anxious about something. So if I do XYZ, then I won't have to worry about this one thing.

The problem is that the thing my brain is currently freaking out about (did I exercise enough? Did I ask the right question during the interview? Did the person I was interviewing think I'm a dumbass?) really isn't relevant to what I'm actually anxious about, which is the boatload of uncertainty in my life right now. Being compulsive fixes these little worries (do more exercise, double-check the interviews, nitpick over their transcriptions, analyze the questions you asked) but it really does nothing to address that big, looming question.

But at least that one worry is fixed, right? At least then that's one thing I don't have to worry about.

Except that outside of my OCD-wired brain, I'm not actually worried about these things. They're a smokescreen. Or a record that gets stuck. You know, the old black vinyl circles that our parents (and occasionally some of us aged bloggers) used to listen to. If the record got a scratch, the needle couldn't translate the sound right because it got stuck on the scratch. It couldn't play any further. OCD is like that stuck needle, playing the same annoying two-second stretch of song over and over and over again. It can't get off of it unless you get up and physically move the arm. The entirety of the album is like my overarching worry. Focusing on every little scratch doesn't help you listen to the album.

(Am I totally dating myself here? I owned several records when I was younger, one of which was a Sesame Street album, and also a Debbie Gibson record. There were others that I'm blanking on. Good times.)

So metaphors and reminiscences of the 80s aside, it's easy to over inflate the importance of these nagging worries. Sometimes yes, they do need to be addressed, but sometimes it's just your brain getting stuck. It's easier to focus on silly things you can do something about that a ginormous, looming fear that you can't quite articulate.

Of course, when these nebulous worries plague me, my brain gets stuck more easily. It's almost primed to get stuck on every stupid little thing that comes my way. I don't deliberately try to focus on the minutiae, but that's just where my brain goes. Then I forget all about the big picture because I'm caught up in ridiculous details like "is the fact that I exercised for 27 minutes instead of 30 going to make me gain 10 pounds?"

One not-so-irrelevant detail is that it's bedtime, and sleep deprivation doesn't help one bit.

One of my favorite blogs is F*ck Feelings, and last week, they addressed fear and anxiety. Although not fear per se, but rather our fear of fear and anxiety. Oh dear--I'm making this quite a bit complicated. I'll let "Dr. Lastname" from the blog introduce the subject for me:

Fear isn’t all bad (e.g., fearing snakes goes a long way towards keeping you from poison venom). On the other hand, fear itself is stressful and painful, so our first instinct is to avoid it, no matter what…which is, of course, when things start getting really frightening. No matter how much we want to protect ourselves or those we love, it’s not gonna happen, so we have to accept the unavoidable scariness of life (and anacondas). It won’t necessarily calm you down, but it will give you the strength to do what matters, fear or no.

Anxiety sucks. There's no getting around that. Anxiety is also pretty normal. It's when we organize our lives around avoiding or neutralizing that anxiety that it becomes really problematic. Of course, it's easier to say that when you're not anxious all the freaking time, but that's a bit of a different story.

I'm good at avoidance. Like really, really good. When I get really stressed, I turn ostrich-like and try to avoid whatever is freaking me out. If I'm anxious about making a phone call, I put it off. And off and off and then even further off. If I'm anxious about what I'm going to eat, I used to avoid eating, or eat only a few specific foods that provoked the least amount of anxiety. If I'm anxious about what might happen if I don't exercise, I just make sure I exercise. The more I avoid these things, the more fearful I become. It becomes more and more certain that something bad really will happen if I make that call, eat that food, or skip that workout.

From the time I was 13 or 14, my life has been dictated by anxiety, be it OCD-driven (mainly germ and contamination fears), about school/work, the eating disorder, or something else entirely. Through recovery from my eating disorder, my anxieties about food haven't gone away. They're still there. What I've learned in my recovery is how not to let my anxieties about food dictate my life. And the more I disregard the dictates of my eating disorder, the less important those dictates really seem.

True, the eating disordered fears still occupy way too much room in my skull. I still do a lot of things to avoid fears about eating more than what my meal plan ways, or exercise less than the maximum I'm allowed, or eat something that isn't the lowest-calorie version. Some of the reason I haven't challenged these is that they really haven't gotten in the way of most of the things I want to do. The other reason is that, well, I'm scared. I know the anxiety won't actually hurt me, but I don't relish the idea of provoking the anxiety demon. Best to let it sleep, right?

Except that I can't recover if I allow these pretty major fears to dictate my actions. All I can do is confront these fears and stop letting them tell me what to do.

My history of OCD and current experience of Generalized Anxiety Disorder have made me very, very familiar with obsessing and worrying. It is, quite possibly, the world's most pointless activity--especially since I don't have any control over the things I'm freaking out about!

So when I saw a PsychCentral post on how obsessions can be productive, I had to read it. Because I was convinced the authors were well and truly full of shit. Obsessions make me so anxious I puke. Obsessions make me wash my hands in Clorox, make me run on the treadmill for hours, make me starve myself for days in preparation for a meal out with friends. How could obsessing be productive?

I'm still not convinced that the obsessions themselves are productive, but it's a matter of channeling that productivity into something worthwhile. My friend Jeff Bell calls it The Greater Good. In the PsychCentral post, which reviewed the book Brainstorm, blogger Susan Perry had this to say:

Writers and other artists are often desperate for fresh inspiration and renewed motivation. By learning concrete ways to tap into the brain’s potential, Maisel’s readers can better move forward in whatever realm they care most passionately about. What the Maisels are talking about here is another way to look at flow, or focus, or deep engagement, or mindfulness. Even if they’re not all defined as precisely the same experience, there’s no particular need to pull apart the threads of difference. They’re all extremely positive states of mind, ones that creative people often crave and benefit from.

PRODUCTIVE OBSESSIONS (paraphrasing Maisel):

1. Are not always easy or fun; but ease, fun, and joy may be part of the process.
2. Are fueled by good reasons, not only love and passion.
3. Need to be strategized. To be continuously effective, you need to plan what you’ll do when you feel anxious or at a dead end.
4. Require stretching. “Expect the emotional equivalent of aches and pains,” writes Maisel.
5. Necessitate switching gears between your normal life and your obsessive life. Learn to do so with the least time wasted and “no internal drama.”
6. Need to be monitored. Learn to pay attention to your state of mind, taking breaks when needed, or devoting a full week to your obsession when that is what’s called for.
7. Are risky. “Take the risk that your project may not prove as important as you had hoped,” notes Maisel. “Take the risk that it will prove exactly as important as you had hoped, taxing you with its difficulty and troubling you by its felt significance.”

As I read through this list of seven things, I thought about how true it was, especially for my blog. It is exhausting and frustrating at times--the writer's block or, at other times, the flooding of ideas--and I think about my blog a lot. It's also true of my life as a science writer and my work as an advocate in the field of eating disorders. I think about these things all the time anyway- I may as well make some good come out of them.

The other reason I was glad to read this was that it showed me that my propensity to obsess about basically everything could actually be a useful skill. It can allow me to immerse myself in my work, focus on one subject and become and expert. Things like this blog and my writing career let me use my skills for good instead of evil.

How do you turn your obsessions into something productive? Share your thoughts in the comments!

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

The International OCD Foundation describes exposure and response prevention as:

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

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

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

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

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

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

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

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

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

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

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

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

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

I'm aware my eating disorder is a problem in my life. I'm not paying The New Therapist (TNT) big bucks because my life is fine and dandy and turning out just the way I hoped it would. I'm also aware that things didn't really start to go to pot until the ED kicked in, full-force. This would naturally lead to the logical conclusion that the eating disorder is a problem. And I suppose, when you look at it in more of a vague, almost existential sort of way, I get that the eating disorder is a problem.

But when I have thoughts about restricting, about hiding food, about exercising, about losing weight...I don't see these thoughts as a problem. It's the things that are preventing me from restricting, hiding food, exercising more, and losing weight that are the problem.

My OCD-type thoughts are distressing, and I view them with a mental "Ew, ick, get that out of my head!." The compulsions aren't welcome, but the (temporary) relief they bring from the obsessing is, and so the cycle begins. If you had a magic wand and approached the teen Carrie and asked her if she wanted the OCD stuff gone from her life, she would have said yes, please, take this away from me.

The anorexia is a little different. I do want the eating disorder gone from my life--it's ruined me in every way I can think of--and I'm no longer in denial about the fact that I do have an eating disorder. But when I have ED-related thoughts and urges to engage in behaviors and even (oh lordie...) actually engage in behaviors, I'm not wishing for some sort of magical fairy godmother to make these thoughts and urges go away. Because these thoughts and urges and behavior seem so logical at the time. Feeling like a fat, lazy slug? Duh- exercise more! Feel that you have to eat too much? Slip those eggs into your pocket.

When I was still working full-time in Corporate America last year and in the throes of my exercise addiction, my presence was requested at a lunchtime meeting. This was problematic because I exercised at lunchtime, and if I was at a Big Meeting in front of Important People and theoretically Representing My Agency, I couldn't very well sit there and not eat. I had several days' warning, which gave me plenty of time to stew about appropriate options. As the day grew closer, I debated whether or not I should fake food poisoning to get out of this dumb meeting. Now, even without any eating disorder I wouldn't have wanted to go to this meeting and probably would have come up with half a dozen bizarre excuses not to go that I never would have had any intention of using. My thoughts about the meeting would have been more like "grumblegrumble...stupid lunchtime meeting...grumblegrumble." I wouldn't have contemplated calling in sick to avoid it. But in my mind, the problem wasn't that I was so addicted to exercise that I couldn't contemplate even taking a small break or changing my routine. The problem was (you guessed it) that stupid lunchtime meeting.

In the end, I went to the meeting, divided up my usual lunchtime exercise and tacked it onto the next two days' evening routines.

I'm often unsure about whether I see the ED as sort of a foreign invader or as just a really f*cked up part of my own brain. In a sense, I suppose that's not as relevant as seeing that voice as something I should fight, something I should want out of my life. I struggle every day to see the ED as the problem, and I haven't been able to do it. I suppose this is what the psychologists mean when they define an illness as "egosyntonic." I want it anorexia to disturb me, to fill me with a shuddering dread whenever I think about ever deliberately skipping another meal or tethering myself to a StairMaster. I suppose that's a start, because for so many years, I actively welcomed the anorexia. Even now, though, I find the idea of "having" to eat a meal when I don't want to or not being able to exercise when I want/need to as being the actual problem, not response. I don't know how to get to the point where I actively start fighting the ED off, because when push comes to shove, the thoughts and behaviors don't seem all that problematic.

How did you integrate the idea of "ED as a problem" into your own recovery?

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

Writes psychiatrist Ahmed Okasha:

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

(Emphasis mine)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I've heard talk of the greater good plenty before. People donate money for the greater good. They "take one for the team." And so on. The idea is that a small, personal sacrifice right now will yield greater benefits in the future.

I'm pretty talented at delayed gratification--in fact, I'm pretty sure it's the only real way I know how to gratify myself. Outside of the fact that I've managed to equate denial with happiness, I really get the idea of the greater good. I get how it works, and I like the idea. Because it isn't all about me.

To some extent, I thought the eating disorder was operating on the plane of the greater good. I was denying myself something now (food, rest, free time), for a tremendous payout later (feeling like I was good enough). The eating disorder really didn't work like that, as my self-denial was really an attempt to nullify the anxiety I felt about needing anything. The end goal was subsumed in the here and now minutiae of anorexia, the calorie counting, the tallying of sit-ups and push-ups, the Holy Grail Quest for calorie-free food.

The writer of an OCD blog, titled "Beyond the Doubt," used the idea of the greater good in his own recovery from OCD, and has a developed website called Your Greater Good. The idea is that the OCD rituals feel good right now. They make the anxiety better, and are classified as a "good" choice. However, in the long run, the obsessions and compulsions only make you feel worse. They don't free you from what you fear; instead, they tether you to it even more strongly than before. This makes engaging in OCD behaviors not such a "good" choice. The idea, then, is to find something of greater good than your rituals, something that can provide perspective and motivation to allow you to make the more difficult decision to resist the anxiety.

I've found this idea to be tremendously helpful to me in my own recovery. I enjoy the advocacy work that I do, and it's not about making the eating disorder "worth it." It's about making the pain of recovery worth it. Much of the time, my greater good has nothing to do with eating disorders. It might be the opportunity to travel. It might encompass being there for a friend. A huge motivator for me is that I promised Aria I would never, ever leave her again. That keeps me going when few other things can.

So what's your greater good? How can you use it to keep moving forward in recovery?

Orthorexia nervosa, or an obsession with "healthy" or "pure" eating, is generally considered a type of eating disorder, even though no formal definition exists. Clinicians have been saying that this unhealthy obsession with healthy food has been increasing the past few years, and I wouldn't be surprised if that was the case. Becoming more aware of what we eat (which is good) has also fueled the worries of those who aren't sure what to eat. Everyday, it seems, some new research adds another item to the litany of things we should and shouldn't eat.

How could you not be anxious?

Steven Bratman originally coined the term "orthorexia" in the 1990s, after himself suffering from the condition, and explains it as follows (excerpted from a Smithsonian Blog on the subject):

“Orthorexia begins, innocently enough, as a desire to overcome chronic illness or to improve general health,” he writes. “But because it requires considerable willpower to adopt a diet that differs radically from the food habits of childhood and the surrounding culture, few accomplish the change gracefully. Most must resort to an iron self-discipline bolstered by a hefty dose of superiority over those who eat junk food. Over time, what to eat, how much, and the consequences of dietary indiscretion come to occupy a greater and greater proportion of the orthorexic’s day.”

I started to twitch just a bit when Bratman says "willpower." Because it's not willpower. It's fear. And fear is a remarkably strong motivator. Sufferers of orthorexia aren't avoiding foods because they're "better" or "stronger" than those Oreo-loving, Cheez-Whiz guzzling "normal" folks. It might seem that way--when I was restricting, I often used words like "strength" or "willpower" as so-called motivation. Yet these words cloaked what was really going on: I was afraid to eat. It's a pretty bizarre concept, when you get right down to it, and my brain understood it much better when I thought I was super-strong because I could exist on a diet of lettuce and air.

A sub-headline on a MomLogic blog post about orthorexia explained it much better: Obsessive-Compulsive Driven Disorder. Although I've never been obsessed with food in a strictly orthorexic way, I do have OCD and anorexia, and I know quite a bit about food obsessions. I wouldn't call anorexia the same as OCD, but there does seem to be a significant amount of overlap, both in personality traits and the percentage of anorexics who also have OCD. And orthorexia also seems similar to OCD, with the obsessions focusing on quality of food rather than calories and fat grams.

But Bratman says there is one main difference between anorexia and orthorexia:

"Someone with anorexia does not see her/himself as emaciated, but as fat. Where someone with orthorexia is aware of their extreme thinness but is fine with this, as long as they feel pure."

Except there are well-known cases of non-fat-phobic anorexia, especially in younger children and non-Western countries. So I'm not sure this difference holds up. Another similarity is the fact that both disorders seem to be largely egosyntonic- their illness is giving them the "desired" outcome.

In the end, both disorders can be deadly and debilitating. We need to learn more about orthorexia so that we can start to define it and devise treatments for it.

Anxiety continues to be my constant companion, and I twitch and jitter to try and work the nervousness out of my system. I didn't have a specific source for the anxiety, though I seldom do. All I know is that this anxiety is really making me want to exercise. Like run-til-my-shoes-wear-out exercise. It makes me feel better. I took a brief walk yesterday, which helped, but it didn't quite seem like enough to neutralize the anxiety. I still tap-tap-tapped my knee as frenetically as ever, and I could hardly stand to sit still (as evidenced by my lack of posting yesterday. I can tweet on my phone, but I'm not yet talented enough to blog).

This complicated relationship I have with exercise--well, when you get right down to it, it's not that complicated: I'm addicted--was explained a lot by some new research in the Journal of Anxiety Disorders:

Acute changes in obsessions and compulsions following moderate-intensity aerobic exercise among patients with obsessive-compulsive disorder

The researchers found that

Participants reported reductions in negative mood, anxiety, and OCD symptoms at the end of each exercise session relative to the beginning. Changes in the magnitude of the effect of exercise in reducing negative mood and anxiety remained fairly stable while levels of self-reported obsessions and compulsions decreased over the duration of the intervention. Results of this study point toward the promising effect of exercise for acute symptom reduction in patients with OCD.

Well, it's a good treatment if you don't take it too far.

Research like this makes me feel a little less guilty for falling into the seemingly obvious potholes that were in my way. A lot of anxiety resulted in a lot of exercise. In the beginning of this pattern, if I can even find a beginning, I could have made better choices and extricated myself from the cycle. But the anxiety and restlessness of being on exercise restriction (of which I am partially off, yay me) has also driven home how entrenched in the cycle I was.

If I were allowed free reign over my exercise today, would I go back? I don't know. Part of me knows it's bad and stupid and really pointless, but part of me doesn't know if I'd be able to resist a no-holds-barred access to fitness equipment. Which is why I'm staying away from machines and looking into yoga and dance classes.

In the meantime, I just need to find something that works as well as exercise.

I remember when the OCD first struck. Sure, there had been plenty of signs of anxiety and obsessionality before then, but on one December day of my ninth grade health class, my OCD came crashing down with a thunk. We were learning about AIDS, and I promptly freaked. Freaked is, perhaps, an understatement. I had an anxiety attack so intense that I ran to the bathroom, threw up (not intentionally, I was just so anxious that I couldn't keep my breakfast down), and washed my hands. Twice.

And that was the beginning of that.

I wasn't especially anxious about AIDS before this incident. I mean, I was a little bit, but nothing even remotely crippling. A little anxiety can be a good thing in terms of disease prevention. It might make you think twice before sharing a needle or having unprotected sex with a stranger. But this was the mid-90s, and the second round of AIDS hysteria was picking up. The second round was more a This-Can-Happen-To-YOU kind of moralizing, and news pieces on TV and in magazines only confirmed what I was already afraid of. It wasn't just a random 15-minute video in health class, these fears were all around, all the time. Every article, it seemed, only confirmed my nagging fears that people were simply germ-spreading machines. I was smart to be worried. I was right. Why weren't others so worried? What was wrong with them?

Granted, most people I knew weren't scrubbing their hands in Ajax and puking from anxiety, but still.

The last line in a Guardian UK piece called "Pure food obsession is latest eating disorder" got me thinking along this line. The article looked at the seeming rise in rates of orthorexia, or an obsession with healthy eating. The last quote of the article, by nutritionist Deanne Jade, was what stuck with me:

"And just look in the bookshops – all the diets that advise eating according to your blood type or metabolic rate. This is all grist for the mill to those looking for proof to confirm or encourage their anxieties around food."

This quote reminded me of the beginnings of my OCD: everywhere I turned, my fears were confirmed. I couldn't convince myself that this was not a smart thing to be worried about--or, at least, so worried about. I was aware that my behaviors were bizarre and my fears overwhelming, but when you see all of this hysteria all around you, it's kind of hard to realize that you have an actual brain disease.

Is this rise in orthorexia a bit more complex than this? Of course it is. There has been an increase in a wide variety of specialty foods that allow people to custom build their diets. For those with real dietary limitations, this is great. But it also has allowed those who have food anxieties to avoid anything anxiety-provoking. And as someone with plenty of food anxieties, I can attest that any magazine will confirm my fears of becoming fat or of eating too much or of not eating the "right" foods in the "right" quantities at the "right" times.

A little anxiety over food isn't necessarily bad. Roaches don't add flavor, and neither does Salmonella. But considering how much we are all fanning the flames, it's little wonder that the severe, clinical fears are only rising.

I've been on exercise restriction for the past two months as I try to get my weight back up where it needs to be, and the reality of it is that this sucks. I really miss exercising. I know I was struggling with an exercise addiction, and that some of this craving is not altogether healthy. But some of what I miss about exercise, I'm coming to learn, has very little to do with exercise itself.

First, let me set the scene of one of my usual workouts. I tied my hair back with a red bandanna. I wore ankle socks and running shoes. I had my keys, my water bottle, and my iPod turned on full blast. I started each workout with the same song. I've destroyed my knees and ankles through excessive exercise, but I've also probably ruined my eardrums, too. When I hop on the machine, I was usually edgy, twitchy, frenetic, tense. And then I started pedaling/stepping/walking/running/elliptical-ing and all of that edginess began to fade into the background. With each step, each push of the pedals, it faded further away. By the end of my workout, those stresses were X hours or X miles away from me.

At the end of my workout, I would let out a deep breath. I could breathe again. I listened to my post-workout song on my walk back to my apartment (I only let myself listen to this song if I completed the entire workout). It was my ritual: song, shower, PJs. OCD much?

While I was exercising, I felt untouchable, invulnerable. Not in the sense that nothing could ever happen to me while I was exercising, because I was voted class klutz in high school. Getting smacked in the face with a kickball in high school gym, such that my braces were jammed into my cheek and had to be yanked out was more than enough to prevent that delusion from ever returning. But untouchable in the sense that nothing could bother me. I didn't have my cell phone, so no one could intrude. The blaring music from my iPod literally blocked everything else out. I was in my own little zone in my own little world.

And that is what I miss- the distance from all of the things that are bugging me, that block of time in my day (or blocks of time, to be really honest) when I wasn't constantly obsessing over everything. I sort of loosened the reins on my brain and just let it wander wherever it felt like. Some of the daydreams were ED-related, but many weren't. Sometimes, I didn't exactly think at all. No one could need my attention because they couldn't get it. I was away from my phone and email and whatever it was could and would wait. All of the stresses, those things I needed to "fix," such as folding the laundry and cleaning Aria's litter box, were somewhere else. However sweaty and stinky and exhausted I was when I was chained to my exercise machines, I wasn't interrupted, I wasn't bothered, and I felt at peace. It was like Calgon had taken me away.

My cousin's wedding this past weekend was stressful, both in ways I've mentioned, and ways I haven't. All I wanted to do last night was go for a long, sweaty run and let the pounding of my feet replace the pounding in my head. And I couldn't. So I let the hot water in the hotel shower pound on my back and slow my racing heart, taking deep, raggedy breath after deep, raggedy breath. I felt better after my shower, but it wasn't the same. I had to take a step off the beaten path.

I know that part of me misses that almost constant movement and my body literally craves a physical outlet for all of my anxiety. And exercise did help me deal with stress in a healthy way at first, and that's what I ultimately want to get back to. In the meantime, I need to find a replacement for all of the non-movement-related things that exercise did for me.

Any suggestions?

It seems odd that I, of all people, would have to remind myself of this. I can (and frequently do) go on hour-long diatribes about the real nature of eating disorders to anyone and everyone in earshot. It makes perfect sense that EDs in other people are mental illnesses because I can see the distortions. I understand how a nibble of a Saltine can seem like "too much food" or how running a marathon can be "too little exercise." I understand it and yet I can see that it's not exactly reality.

My problem is that when I'm thinking these things, they seem perfectly rational. If I had vowed not to eat lunch, and then had a nibble of a cracker, I would have griped about how much I ate. Because a nibble is more than nothing, I clearly ate too much. It doesn't seem distorted in the least. It seems normal and (dare I say it?) sensible.

This is where I have problems. I have a hard time understanding that MY distorted thoughts are symptoms of a mental illness.

I can compare my ED experiences with those I've had with depression and anxiety. I became inured to the mild depression and anxiety that characterized my life, to the point where I kind of stopped noticing it. But when I get really depressed or really anxious, I don't feel like me. I've never been high-energy, but when I don't even want to get out of bed, that doesn't seem like me. It's not pleasant. Taking a shower and going back to bed might be the actual best I can manage, but it's still not pleasant. When I first developed OCD in high school, I thought I was going crazy. I knew that my touch probably wouldn't cause someone to die of AIDS but I was so terrified it might that I washed my hands and tried not to leave the house if I could avoid it. I didn't know that this was , in fact, a mental illness called obsessive-compulsive disorder, but I was able to recognize that something was wrong. More than that, I was aware that other people knew that this was very bizarre behavior.

The anorexia was very, very different. Basically night and day different. Eating less and exercising more seemed very normal and rational and common. I got compliments about how "good" I was being. No one complimented my freakishly clean hands (thanks, Clorox and Ajax!) even though they were freshly scrubbed. No one complimented my ability to stay in bed all day or scream and cry and throw things at the drop of a hat. I had excuses for all of my odd ED behaviors. I had excuses for all of my other odd behaviors, too, but with the ED, I actually believed my own bullshit.

I seriously began to believe that a sip of water would make me fat, that I just "didn't like eating," that I worked better on an empty stomach, that I simply adored the treadmill. There were definitely OCD moments when I believed I was a death- and disease-spreading machine, but these moments also passed. The AN delusions didn't.

Although I continued to lose weight, I wasn't able to see it in the mirror. The number on the scale was different, my clothes were looser, but I still looked the same. Ergo, I must actually look the same. I could tell when other people had cut their hair or lost weight, so the same must be true for me, right? So if my mom is telling me I'm way too thin, I'm emaciated, I'm dying, and I can't see it, it must not be true. I mean, I know what I look like...don't I? I will eat, I told myself, when I see that I'm too thin. Oddly, this is the same trap I fell into on this latest relapse- I couldn't see a difference in how I looked in the mirror despite my almost hourly trips to the bathroom scale.

When I am really depressed or really OCD/anxious, I can tell a difference between those states and my "normal" state. When I am into the ED, it's much harder. I feel almost more like myself--more intense, more driven, more on top of things, in a sense, I feel like a better version of myself--when I slide back into the AN. I can't point to a difference. My mom can. My boss probably could. But if I feel the same and look the same and am just freaking fine, dammit then how in the HELL could I be sick?

How? Because the illness I have, this pernicious eating disorder of mine, makes it very very hard to understand that I am sick. It's one of the symptoms of the illness, this inability to understand that you are ill. Laura Collins introduced me to the term anosognosia and I love that word. Can't pronounce it, but I love using it. The depression and OCD aren't anosognostic- I knew damn well that something was up even if I didn't have a name for it and didn't know that it was a mental illness that could be treated. Anorexia is very anosognostic and it will probably be my Achilles' heel. Not so much the illness itself, but the difficulties in recognizing it.

However untalented I may be at recognizing my own eating disorder even when the evidence is literally staring me in the face, it doesn't change the fact that EDs are mental illnesses. Including my own.

I love analogies and metaphors. Love 'em. So when I saw a post titled "How depression is like the X Files" on the World of Psychology blog, I was kind of intrigued.

Before I get too much further, let me add a full disclaimer: I have never seen The X Files. It doesn't seem that interesting to me, and my innate skepticism keeps the whole "aliens are amongst us!" part of the plot from getting me hooked. But even I understood this post and found the metaphor quite wonderful.

Blogger Erika Krull writes:

They [Mulder and Scully and co.] can’t tell anybody, they don’t know who to trust, and whoever they do tell surely will think they are crazy. Really, who would ever believe that the informant who is trying to feed the agents helpful information really has the scar from a metal chip in his neck because he’s an alien hybrid? Even though all the viewers and the key cast members know all about this threat, the agents never seem to know who they can trust. They live in a world of worry, peril, secrecy, and confusion.

Ta-da. There’s my connection. I have often said to myself that my depression felt like an alien had taken over my brain, though the takeover wasn’t complete because I still knew that I was me. I was just disabled enough to have little control but aware enough to realize I wasn’t able to get the alien out by myself.

I needed help. This wasn’t normal; I knew something was different. But what? And how do I describe this? Would anyone believe me? And would I wish I would have kept my mouth shut once I said something? How will this affect my job, my kids, my marriage? I can’t keep going on like this, but I don’t know if I can tell anyone either. Which is more dangerous?

This perfectly describes my experiences with basically any mental illness that I've had (and the list is long, kids. The list is long). For me, though, the "alien takeovers" where I've felt the most bewildered and confused have been with OCD and with anorexia. When I first developed full-blown OCD in middle school/high school, I had mostly obsessions. I was paralyzed by anxiety, and yet I didn't feel I could tell anyone. My fears were either correct, or they were wrong and I was crazy. I knew my obsessions were bizarre- who would believe me? Half the time, I didn't even believe myself! But I was so worried that I could be right that I kept on obsessing, and later added the compulsions.

When I first got sick with anorexia, I didn't realize I was in an "alien takeover" situation. I thought I was fine and dandy- everyone else had those problems. I would imagine that my parents felt an awful lot like Mulder and Scully, trying to convince people that I did, indeed, have a problem. Many other caregivers have probably had this same situation, especially in the first days before the eating disorder becomes patently obvious to anyone who cares to look.

Now that I'm more healthy and more aware, the anorexia is much more frightening. Not always, of course, but I think that fright is healthy. I can perceive when I am starting to loose control a little bit quicker. I am trying to identify which thoughts are from the healthy (or trying-to-be-healthy) Carrie, and which are the voice of Ed. They're not always that different, which is also really frightening. That's probably how I got in trouble with the exercise this past time.

I ultimately have to keep the "aliens" at bay, and learning how to respond when I sense they're trying to take over my brain is probably going to be a key part of that.

Their eyes might have been watching god, according to Zora Neale Hurston, but my eyes were watching Lisa.* Lisa is one of my co-workers. I work in a moderately large office, although I don't always interact with other people on staff a whole lot. The times when I do tend to be, alas, in the kitchenette.

Some of my co-workers have a dysfunctional relationship with food. It's obvious--to me, anyway. Some appear more outwardly normal. And then there's Lisa.

She's almost like a breath of fresh air. It sounds cheesy, and maybe it is, but that's really how I feel when I'm in the kitchen with her. The most revolutionary thing about her? She never apologizes for eating. Or makes any excuses. None of this "I shouldn't but I'm gonna," or laments of how much she'll pay for this at the gym, or saying she was "good" yesterday so why not?

She'll just look at the tray of whatever someone brought in, say something like "That looks good," take it, and leave. Or just look, think for a second, and leave. No drama. No Second Book of Lamentations. No calorie counting abacus going clickety-clack in her brain.

Mostly what astonishes me about Lisa is her coffee. She goes to Starbucks pretty much everyday, and she gets a latte, extra hot. After she finishes her latte, she makes a mocha using supplies in the kitchenette, namely hot cocoa mix, a packet of Splenda, two coffee pouches,** and two little tubs of flavored coffee creamer. Not the plain Mini Moos, but the actual flavored kind.

This boggles my mind. Absolutely boggles my mind. The hot cocoa mix has calories, and ditto for the coffee creamer. And yet there she is, drinking them nearly every day. Drinking them and enjoying them, as they were meant to be enjoyed.

When I make my coffee, I use the actual coffee pouch, some sweetener, and I hesitate at the box of Mini Moos. I know each little tub has 10 calories (it's printed on the box they come in), and I sit there and think through everything I have eaten or have planned to eat and try and determine if those 10 calories will make a difference. I do the mental gymnastics of calorie counting: will this little tub of creamer push me over the line into "too much"? Will it make my totals come out to a "not nice" number? Am I being greedy? Gluttonous? Is this stupid little tub of creamer just simply too much?

Yes, sez my brain. Yes it is. So I go without.

Rationally, this makes no sense and I think I even understand on some level that this makes no sense. That when you're moderately hypermetabolic, 10 calories is like pissing on a forest fire. It's nothing. And that my body doesn't "count" calories in the way that my brain does, that my ATP synthase enzymes don't really give a crap about the OCD hocus pocus that makes my anxiety just a teensy bit better.

Except eating disorders aren't rational. And I fear saying yes far more than I fear saying no. I fear the process of deciding and having to live with my decision even more. I'd rather deny myself than deal with the invariable guilt that comes from opening the creamer and putting it in my coffee. I'd rather deal with regret than live with guilt.

Why guilt over coffee creamer? Maybe the answer is as simple as I have an eating disorder and it's part of the territory. Maybe it's as complicated as wanting in a culture that systematically denies your appetites, or finding it easier to say no than yes.

To Lisa, it's just coffee creamer. And that's why I stand back and just drink it in, hoping that her spirit will rub off on me, just a little bit.

*Not her real name. And not any of my other co-workers' names, either. I just felt weird using her first initial throughout the entire post, so I made up a name.

**We have a Flavia machine that brews individual cups. It's a bit of an environmental disaster, but seeing as no one can remember to refill the water cooler, I'm not thinking a communal coffee pot would be successful.