Much of the writing about anorexia is couched in the terms of mind vs. body.  Perhaps it is something of the nature of eating disorders; perhaps it is our conception of what an eating disorder is.  As hunger pulls at your gut, you tell yourself "mind over matter," as you crack open yet another can of Diet Coke.  Starving, you tell yourself, is an all-out war with your body, and your mind is determined to win.

Recovery, then, seems like capitulation.  Surrender.  Okay, stupid body, you win.  I'm waving the white flag. You couldn't vanquish your body and so you break down and eat.

Or, in my case, lay off the exercise, too. 

This past slip didn't see a return of the full-blown exercise addiction that I've shown in the past.  But the urges did increase somewhat, and now I've been advised to basically cease all activity until my weight starts trending upwards.

I know my body needs this to heal.  I try to think about my heart, liver, and kidneys.

But then I start worrying about my mind.  How am I going to stay sane if I am sedentary?  Some people exorcise their demons, but exercise mine.  The repetitive motion is soothing--I'm like a baby being rocked.  And as much as I hate the fatigue, it does turn the volume down (however slightly) on the worries and obsessions.

So exercise right now seems good for my mind and bad for my body, which pits me right back at the crux of the matter.  Of course, exercise addiction is a Very Bad Thing for my brain over the long term.  Anxiety, however, rarely takes the long view.  Sure, it obsesses about the future, but when in the throes of anxiety and stress, all I'm thinking is make this stop NOW.  The long term can go screw itself for all I care.  I'm not going to be around for the long term if I can't ratchet down the anxiety--or at least, not around and sane.

I'm struggling to find something half as soothing as exercise.  Today was especially hard, as the day was warm and sunny.  Perfect day, I thought, for a bike ride.  Except, oops, I messed up and now going out for a spin wasn't in the cards.  So I crocheted this evening, all gloom and doom and look at me working on this motherf*cking project like a good little girl. Woo woo. {{Say it in an Eeyore voice.}}

Healing my body will heal my mind.  I'm trying to tell my fat starved neurons that avoiding a good sweat is good for me, really it is.  My neurons aren't buying a word of it.  That doesn't make it untrue, just pathetically unbelievable. 

I was chatting with one of my co-workers today in the bakery (though not the one who told me to "let my titties hang out"), and griping about always being hungry because my metabolism is now fighting back. Between work and my recreational cycling, my body needs a lot of fuel. I'm not exactly fond of this always hungry state. It's pretty annoying. But my co-worker looked at me and said:

"Isn't the point of cycling so that you can eat everything?"

I thought, hmmm, that's interesting. Although I am still very aware of the fact that exercise burns calories--both from my ED history and from the fact that living in this culture, it's kind of hard not to be aware of it--that was never my motivation for starting to exercise. I did it to manage stress and to improve my health. Did I harbor secret fantasies about losing weight because of my new exercise habits? Yep. But that wasn't the sole reason I was exercising.

Even at the height of my eating disorder, the exercise was as much an OCD ritual, an addiction (damn didn't I loves me some endorphins), and a way to absolve guilt over eating (my therapist didn't describe my routines as "punishing" for nothing) as it was a way to burn calories. After a while, I didn't really have a motivation for working out- it was just something I had to do, like brushing my teeth and wearing deodorant. I did feel extremely guilty for not burning calories when I didn't exercise, but it wasn't a major motivator.

I've been trying to break my OCD obsessions with counting calories, miles biked/run/climbed, speed, etc, by avoiding exercise machines. It just makes it too easy for me to obsess over this minutiae that the ultimate goal of exercise--the stress relief, the enjoyment of it--gets lost. Buying my bike was a big step in this direction. Exercise still has the connotations of weight loss about it, and I guess given my history that shouldn't be all that surprising.

But the one thing that made me laugh about my co-worker's comment was that I couldn't understand why someone would want to eat more? It's annoying. I have to think about food even more than I already am, just from a practicality standpoint. I have to spend more time on food prep and grocery shopping. All around, I wish I could do my biking and not have my metabolism be all "FEEEEEEEEEED MEEEEEEEEE!!" like the plant in Little Shop of Horrors. Even though I haven't lost weight while riding my bike or being on my feet, I continue to do them. I know that the benefits my rides (and my job) give me make the extra calories worthwhile.

Although my co-worker's comment did make me laugh a bit, it also made me realize just how much exercise and weight loss are linked in our culture, and how so many other factors played into my exercise issues. It also made me realize that the idea of me, biking for the sheer enjoyment of the wind in my hair--in my helmet, really--makes me pretty unusual. All I can think is how much nicer the world would be if we all got back to this primal enjoyment rather than the drudgery of calories burned.

A few days ago, I was in a sporting goods store with my mom, helping her pick out a mat for her new Pilates class. We passed by the elliptical machines, and I thought I saw one with an iPod dock and (get this!) built in speakers. So I stepped in the little foot thingies--I'm assuming there's an actual name, but it totally escapes me right now--to get a closer look at the iPod dock.

This was not a smart idea. I didn't exercise in the store, other than about a half a stride to steady myself on the foot thingies, but since then, I have been craving exercise machines like, well, like a junky.

Hi, my name is Carrie, and I'm an exercise addict.

I haven't ridden my bike at all this week, as the weather has been freakishly cold, even for this Midwestern native. I started Pilates classes, which are fun and challenging in ways that my cardio marathon sessions never were. Those sessions were a question of endurance, and part of the hook of working out was just to see how hard I could push myself on so little food. My Pilates classes are challenging in that it's hard for me to coordinate positioning my body, doing the breathing, and everything else that goes with it.

The interesting thing is that I'm not craving a bike ride (although I do wish the weather would warm up because I miss riding) or an extra Pilates class. No, I'm missing that damn elliptical machine. All I can think about right now is that machine and the stupid little red flashing lights and yes, that having an iPod dock and speakers would be awfully fun. Except that fun wouldn't last for very long before the trouble started. In a sense, I suppose that being so particularly attached to the machines is a good thing because it doesn't rule out other forms of activity. It just means that I probably shouldn't be setting foot in a gym anytime soon.

The other interesting thing is that the exercise cravings are a (relatively) new phenomena with my eating disorder. Before, I used to mostly miss restricting, or occasionally, purging. My ED-related "urges" were mostly to skip a meal. Not that I don't have those urges now, but it seems that this past relapse altered some of the behaviors that I find myself missing somehow. A lot of it is the exercise and the endorphin rush, but some of these feelings of "missing" exercise has to do with both the routine I had in place for so long to accommodate all of the exercising and the self-identification I had as Carrie the Exercise Freak. I miss the utter certainty I had in knowing exactly what I was going to be doing at every moment in time. I'm far from bored, but my schedule has been much freer since starting to do freelance writing full time.

The identity issue is another thorny one. I don't identify as an eating disordered person and nothing else, but the eating disorder has been such a part of my life for so long that I often feel lost trying to navigate my way through life without having anorexia as my Plan B. This is perhaps not one of the most savory thoughts I've ever had--nor is it particularly flattering of my character in general, but it is what it is--but I miss the feelings of "virtue" I had when I was uber into exercise. I liked knowing how mentioning one of my several daily workouts would give me a social pat on the back. Yes, it was irritating because I knew I wasn't exercising because I wanted to, but it also provided a shred of self-esteem for me. Maybe it was a half of a Milk Bone when I needed a can of Alpo, but nonetheless, it was self-esteem. When I seemed to screw up everything else I did, at least I could be really good at exercising and losing weight. Also losing my mind.

I don't know if there is a solution to these exercise cravings, other than to keep avoiding machines, maintain my activity at a level my treatment team approves of, and trying not to judge myself too much for having these cravings. One step is that I'm naming and admitting these cravings for all the world to see, and I think I need to accept that missing my ED behaviors in a sense is a normal part of recovery. It's not freakish and doesn't make me a bad recovery advocate and doesn't mean I'm doomed to have these thoughts for the rest of my life. It just makes me real.

On tonight's episode of "This Emotional Life," a recovering alcoholic shared his story, and the importance of the fellowship he found in Alcoholics Anonymous. Although I can definitely relate to the benefits of fellowship--just look at this blog!--it was another comment by this man that struck me as just so wise.

"There's no cure for alcoholism," he said, "but there is a solution. And that is to stay sober."

It's rare that you can combine realism and hope in a sweeping statement about addiction or any other mental illness, but this completely captures my views on recovery from an eating disorder: there's no cure, but there is a solution. That solution is to keep eating, to maintain an appropriate weight (whatever weight your DNA prefers), to stop binge eating and purging, and to reach out for support when these behaviors start to sound even slightly more appealing.

The other truth is that the solution to alcoholism or ED isn't like the solution to a math problem. You do the math, scribble in the margins, and there you have it. The Answer. You may get it right, you may get it wrong, but you can move on to the next problem. The solution to these mental health issues isn't something you can check off on a to-do list. You have to put it on every to-do list you write, every single day, for the rest of your life. And that is overwhelming to contemplate. Massively, majorly overwhelming. So much so that calling it a singular solution seems kind of ludicrous. It's more like that there are millions of solutions, solutions that you have to find and choose every single day.

Frankly, I prefer the math class type of solution.

To some extent, the "solution" seems obvious. Want to not be a drug addict? Stop getting high! Want to not be depressed? Stop being sad! Want to not be anorexic? Stop starving yourself! How did we not think of this sooner?!? I knew for years that if I wanted to recover from my eating disorder that I had to eat and gain weight. I knew that the weight I was maintaining wasn't conducive to health. But I had two major questions to answer: how do I get better, and how do I stay better? The "solution" isn't so much eating; it's figuring out what I need to do in order to keep eating, even when that's the last thing I want to do. The "solution" doesn't mean never wanting to lose weight again, or always approaching every meal with gusto. It just means that you approach every meal.

I'd love for there to be a cure for eating disorders, but I'm not exactly holding my breath. There is just too much that we don't know. But we do have a solution, and that might just be enough.

I've been pretty honest here on ED Bites about my struggles with exercise addiction and anxiety, both of which have played a large role in the formation and maintenance of my eating disorder. I began formally exercising in college as a way to "get in shape" and also because I heard exercise was good at helping people manage stress. I was stressed to the max, having leaped right into all sophomore classes my freshman year, and so I began the daily trek to the fitness center at my college.

Before my eating and exercise turned pathological on me, and even now that I am in a very different place, recovery-wise, my exercise sessions were very therapeutic. I do feel better--mentally and physically--after a ride on my bike or a brisk walk. In the past, though, when my anxiety has risen from its usual normal highs into the stratosphere on a straight shot to the ex-planet Pluto, I became dependent upon exercise to help manage this anxiety. And I needed more and more exercise to get the same effects. In short, I was in trouble.

The link between exercise and reduced anxiety is fairly well known in psychology and neuroscience circles, but scientists had yet to figure out how exactly this worked. At this year's annual Society for Neuroscience conference, a group of scientists presented research results that give some indication as to how exactly exercise could help with anxiety management.

From the Well blog by Tara Parker-Pope:

In the experiment...scientists allowed one group of rats to run. Another set of rodents was not allowed to exercise. Then all of the rats swam in cold water, which they don’t like to do. Afterward, the scientists examined the animals’ brains. They found that the stress of the swimming activated neurons in all of the brains. (The researchers could tell which neurons were activated because the cells expressed specific genes in response to the stress.) But the youngest brain cells in the running rats, the cells that the scientists assumed were created by running, were less likely to express the genes. They generally remained quiet. The “cells born from running,” the researchers concluded, appeared to have been “specifically buffered from exposure to a stressful experience.” The rats had created, through running, a brain that seemed biochemically, molecularly, calm.

...Anxiety in rodents and people has been linked with excessive oxidative stress, which can lead to cell death, including in the brain. Moderate exercise, though, appears to dampen the effects of oxidative stress.

...“It looks more and more like the positive stress of exercise prepares cells and structures and pathways within the brain so that they’re more equipped to handle stress in other forms,” says Michael Hopkins, a graduate student affiliated with the Neurobiology of Learning and Memory Laboratory at Dartmouth, who has been studying how exercise differently affects thinking and emotion. “It’s pretty amazing, really, that you can get this translation from the realm of purely physical stresses to the realm of psychological stressors.”

Precisely what causes some people to slide over from the beneficial anxiety-reducing effects of exercise and into exercise addiction is unknown. Some of it might be a growing tolerance to the anxiolytic effects of one's current exercise program. Some of it might have something to do with dopamine and the brain's addiction circuits. And some of it, I can't even guess at.

For me, the exercise was a time when I would "hide out" from my anxiety. When I was exercising, I had my iPod blaring and my cell phone switched to vibrate. The report that was due at work the next day didn't matter while I was working out. Figuring out how to pay the bills didn't matter. My sad, pathetic excuse for a social life didn't matter. In the same way one of my friends would stay in bed all day when her anxiety got really bad, I stayed at the gym all day. After exercising, I was usually too exhausted to care much about the things that were making me anxious.

Still, the understanding of how our brains respond to exercise is fascinating and important in helping people better benefit from physical activity and in understanding how to better treat exercise dependence and addiction.

One of the questions I get a lot when people hear about my eating disorder history is usually some variant on: but how did you resist all of that tempting food? (This is usually said dripping with the unsaid phrase of "please teach me how you did this.") My answer is that anorexia made me afraid of food. Not that I wasn't hungry or wasn't utterly obsessed with it, just that the prospect of facing food gave me that deer-in-the-headlights feeling.

Now, if we want to talk about temptation, we can talk about the allure of the anorexia symptoms. I'm not so delusional as to think that losing weight will be a cure-all for everything that is wrong in my life, but I have been so delusional as to think I wouldn't become addicted to exercise, or that I could lose five pounds and be absolutely fine, dammit. Uh, not so much. Eating dinner every day really does matter, and so does making sure I have at least one rest day each week from exercise.

Which is why this study on restraint bias (called The Restraint Bias: How the Illusion of Self-Restraint Promotes Impulsive Behavior really interested me: it seemed to echo my own thoughts that I really wasn't all that vulnerable to relapse. I mean, hey- I've written two books on eating disorders. Surely I'd know the danger signs.

Except that it doesn't work that way.

Ed Yong, in his blog Not Exactly Rocket Science, has a great explanation of this study, and summarizes the study as follows:

The restraint bias stems from the fact that we're generally bad at predicting the future and how we'd feel in circumstances that are different to our current ones. When we're full, we underestimate the powerful pangs of hunger. When we're cold, we can't imagine what it's really like to be sweltering. Addicts underestimate the pull of their drug-of choice when they try to quit.

{snip}

The restraint bias could also help to explain why people willingly take up activities they already know to be addictive - they simply believe that they're strong enough to resist the addiction. As a powerful example of this, one study showed that heroin users are less willing to pay for the substitute buprenorphine if they weren't currently experiencing cravings. If experienced users underestimate their urges, imagine how monumentally more difficult it would be for a naive person to do so.

Restraint bias is the idea that we often think we are better at resisting temptation than we really are. A smoker may underestimate the strength of their cigarette cravings when they're in a smoky bar. Someone with binge eating behaviors may take home leftover cake for their family to enjoy, pretty sure that they won't be tempted to eat it. Or, like me, you may think you can skip dinner once and it won't become a habit. Or that you will pack your schedule full of activities and jobs, positive that you will still find time to eat.

This is really life's way of knocking you on your arrogant ass, over and over and over again. And the only way to deal with this restraint bias is to learn humility. To accept that one skipped dinner is never just one skipped dinner. To be always aware of the pull of this behavior. This is not to say that full recovery isn't possible. I know there are plenty of people who are completely free of eating disordered thoughts. But efforts to stay recovered and healthy are different than efforts of constantly fighting off an illness.

I never thought I couldn't relapse or wouldn't relapse, but I sure thought it would be more difficult than it was. Looking back, I can see that I was teetering on the edge of a relapse for a good long time, and that it didn't take much to push me over into the "let's starve!" mode. I underestimated how rapidly exercise would become addictive, and how difficult it would be to just stop. I didn't realize that I couldn't just flip a switch in my brain and start eating again. Which is restraint bias at it's finest.

My recovery journey has been humbling and, at time, humiliating. But I think that ongoing self-awareness will help keep me well, and keep me on my toes.

I was on the great Neuroscience and Society website at the University of Pennsylvania, looking up more information on the 2010 Neuroscience Boot Camp (which I really hope to attend, provided I can snag both an admission spot and a scholarship), when I checked out their full-text research articles published by members of the program. One, titled Denying autonomy in order to create it: the paradox of forcing treatment upon addicts, immediately caught my eye.

(Just to warn you: the article is full-text, but it's really blurry. It appears they scanned in printed pages to create the .pdf files, so you can't copy and paste the text into word to get a better look. And no, printing it doesn't help either. I apologize if there are any errors in my transcription of the text.)

The author, Arthur Caplan, writes:

People who are truly addicted to alcohol or drugs really do not have the full capacity to be self-determining or autonomous. Standard definitions of addiction cite loss of control, powerlessness and unmanageability. An addiction literally coerces behavior. And addict cannot be a fully free, autonomous agent precisely because they are caught up in the behavioral compulsion that is addiction. If this is so, at least for some addicts, then it may be possible to justify compulsory treatment involving medication or other forms of therapy, if only for finite periods of time, on the grounds that treatment may remove the coercion causing the powerlessness and loss of control.

Addicts, just as many others with metal illnesses and disabilities, are not incompetent. Indeed, to function as an alcoholic or cocaine addict one must be able to reason, remember complex information, set goals and be oriented to time, place, and personal identity; but competency by itself is not sufficient for autonomy. Being competent is a part of autonomy, but autonomy also requires freedom from coercion. Those who criticize mandatory treatment on the grounds that an addict is not incompetent and thus ought not to be forced to endure treatment are ignoring this crucial fact. Addiction, bringing in its wake as it does loss of will and control, does no permit the freedom requisite for autonomy or self-determination.

The parallels to eating disorders are striking and, to me anyways, rather obvious. I believe that legal coercion should be a last resort measure. No one wants this- not the sufferer, not their family, and typically not society either. Buy-in is important in a therapeutic relationship, but if you never get sober, down from your Mt. Everest-level highs or begin a normal pattern of nutrition, "buy-in" is kind of irrelevant.

Coercion, even if it's not of the legal variety, is a commonly used tactic in both addiction treatment and eating disorders treatment. Done right, it can be seen as beneficial, even to the sufferer. Loving coercion could be financial ("I'm not paying for college if you're not healthy"), practical ("I don't think you should drive the car until you are doing better"), and even emotional (refusing to engage the person's disordered behaviors). Most sufferers, myself included, typically don't respond to these efforts with joy and praise, but that doesn't mean that they're not necessary. Many ED sufferers who felt they were coerced into inpatient treatment ultimately admitted they needed to be hospitalized.

In the end, what's worse: a few months of coerced treatment or a lifetime of an eating disorder?

I found two related stories on exercise bulimia in my news feed today, and although they weren't glaringly inaccurate, there were some aspects I found mighty amusing (but not in a funny way).

The two stories were: Emerging Eating Disorder- Exercise Bulimia, and San Diego Clinic Helps Exercise Bulimics. The first aired on the CBS "Early Show," and the second appeared to be from their San Diego syndicate.

First of all, exercise bulimia isn't an "emerging" disorder. It's a fairly new name for a really old phenomenon. When the first clinical descriptions of anorexia were written in the 1870s, doctors noted the patients' hyperactivity in the face of starvation. Compulsive exercise has long been a feature of eating disorders, and our current cultural obsession to try and burn off excess calories through exercise only feeds this mentality and normalizes the disorder.

Secondly, a link on "related articles" on the first piece linked to an item called "Want to Lose Weight? You Gotta Work Out."

I mean, Holy Irony, Batman!

Also, very 80s graphic they have going there. Yikes.

Thirdly, the text about the San Diego clinic opened with the following: For most of us, hitting the gym is a necessary evil to keep those extra pounds at bay.

*headdesk*

This just confirms that so many people just don't get it. The mentality that exercise is all about weight loss and that more exercise is better because it means more weight loss and dedication only fuels the problem. During my exercise addiction, no one ever asked if I had better things to do than live in my rank sports bra. I get that these articles are meant to be helpful, but they also continue the subtle misinformation about the nature of these disorders.

I think most people have some sort of functional addiction- that is, a mild addiction that really doesn't interfere with life and health. You could probably put my obligatory morning 2-3 cups of coffee in that category. Sure, I've been a nasty coffee fiend, usually in concert with the eating disorder, but mostly, I just love coffee. And caffeine. I hate mornings, and so I gravitate towards anything that might make it just a little bit easier. Am I addicted to caffeine? Probably, a little bit. Does it really harm me? At this level, I doubt it.

My aunt probably has a functional addiction to exercise. The amount she exercises isn't excessive, but if she doesn't get her morning workout, she says she feels cranky and out-of-sorts. Is her exercise harming her life and health? Probably not. Is it still an addiction? I would say so.

I've had both functional and non-functional exercise addictions, and my problem was not only the addiction itself but how it was billed by those around me. When people heard I exercised every single day, rain or shine, snow or sleet, they didn't ask why I didn't want to take a day off or even if I would let myself take a day off. No, they lauded my devotion and willpower, which has led to a hate/hate relationship with that last word. They patted me on the back and told me I was "hard core" and how they wished they could do what I did.

Frankly, I wanted to smack them.

Our culture has a totally screwed-up attitude towards both food and exercise. They're related, to be true, and I have historically been much more painfully aware of the "food" aspect. However, as I've begun to address my exercise issues in therapy, I've started to realize just how blind our culture is to exercise addiction. It's seen as a good thing, not a problem.

Which is why this article from my local paper has me a little bit tweaked: Ultra runner brings sport to Ann Arbor

From the text of the story:

Meet the ultra marathoner. You, too, can be one if you have steadfast willpower, oodles of devotion to training and a true love of adventure.

It sounds so positive, and maybe for many people, it is. But the words "ultra marathoner" immediately raise red flags in my head, and for the man featured in this article, it was no exception.

Asked if running is his first priority, he said, "Absolutely."

"It's like an addiction," said Purdy, a married father and retired Ford employee. "You need to get your fix, otherwise you feel crabby. You don't go to the bathroom the same, don't sleep the same."

And people are celebrating this? Certainly, the man is dedicated and talented. I don't doubt that for a second. But that's not the issue. The issue is that someone admits they have an addiction, and we tell them how much willpower they have. It's like patting a heroin addict on the back for the lengths they go to in order to score some dope. Sounds kind of silly when you think about it. It's not willpower- it's desperation!

I have no idea if this man's health or quality of life is being impacted by this. Maybe it isn't. But I also think we should stop blithely celebrating such addictions, even if they leave someone functional.

I stumbled across an interesting Power Point presentation by Shan Guisinger from the 2004 Human Behavior and Evolution Society in Berlin titled: Is Anorexia Nervosa Addictive?



The information is basic, but provides a good overview of how biology can trap someone predisposed to AN in a viscious cycle of starvation and exercise.

An article from Scientific American by Trisha Gura titled "Addicted to Starvation," fills in many of the gaps of the Power Point presentation and is one of the best pieces on AN neurobiology that I've read. One of Gura's more recent blog posts (Brainwashing in Anorexia: Neuroscientists Weigh In) is also quite good.

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.

New research points to the potent addictive effects of excessive exercise. When exercise-addicted rats were given naloxone, a chemical used to block the effect of opiates, they experienced withdrawl effects, such as "trembling, writhing, teeth chattering, and drooping eyelids," whereas inactive mice did not.

From a press release:

The active rats who had access to food for only one hour a day both ran the most and displayed the most severe withdrawal symptoms. Like people with anorexia athletica, they ran so much that they lost significant amounts of weight. Additionally, the more a given rat had run, the worse its withdrawal symptoms after naloxone. In contrast, regardless of how much they ate, inactive rats responded very little to the drug.

Because of the way the active rats responded to naloxone, they seemed to have undergone the same changes in the brain's reward system as rats addicted to drugs. "Exercise, like drugs of abuse, leads to the release of neurotransmitters such as endorphins and dopamine, which are involved with a sense of reward," noted [lead researcher Robin] Kanarek.

Insights into behaviors that trigger the release of the brain's "reward" chemicals may lead to addiction treatments that incorporate moderate exercise, according to the researchers. The findings also suggest that active rats given limited food may make a good experimental model for studying and developing treatments for anorexia athletica, added Kanarek.

The paper itself (free and full-text!), "Running and Addiction: Precipitated Withdrawal in a Rat Model of Activity-Based Anorexia," had some very interesting findings. There, the authors directly linked the commonalities between drug and exercise dependence. They found that "excessive running shares similarities with drug-taking behavior."

Similarities between the effects of exercise and drugs of abuse extend beyond opiate drugs. Research demonstrating that rats will perform operant responses to obtain access to either drugs of abuse or a running wheel provides evidence of the rewarding properties of both drugs of abuse and running. Moreover, under certain circumstances, such as food deprivation, both drug selfadministration and running escalate and become maladaptive behaviors. These findings suggest that running may be able to substitute for drug-taking behavior. In support of this suggestion, rats running in activity wheels self-administered smaller quantities of opiates, alcohol, and psychomotor stimulants (e.g., amphetamine and cocaine) than rats housed in standard cages.

{snip}

The finding that symptoms resembling those of opioid withdrawal occur in food-restricted active rats may have correlates in clinical populations. Excessive exercise is a common symptom of eating disorders, particularly anorexia nervosa Initially, physical activity is used as a means of weight control, but with time it can become an end in itself. In the extreme, individuals with eating disorders can have difficulty refraining from exercise despite adverse physical consequences (e.g., an unhealthy decrease in body weight; decreased bone density; stress fractures). Additionally, symptoms reminiscent of drug withdrawal, including anxiety, depression, and irritability, often develop when these individuals are unable to exercise. The high comorbidity of drug abuse and eating disorders provides further evidence of a common neurobiological basis for these disorders.

The authors also found that female rats showed much higher rates of excessive running than male rats under similar conditions. Furthermore, the authors noted that they were unable to determine whether the withdrawl was specifically due to the increased exercise, or whether it was confounded by differences in food intake and body weight in the active rats.

I would also be curious to see if people with exercise addiction have higher or lower rates of opiate abuse. I could see it go both ways: higher levels of abuse because your system is "primed" for the flood of endorphins, or lower levels because you're getting those endorphins via exercise. It would be interesting to look at how other addictive behaviors overlap in EDs, and whether relatives of those with exercise addiction have higher rates of other addictive behaviors. The authors also suggested that moderate exercise might be a good prescription for those addicted to opiates as it is a non-maladaptive way to get that nice endorphin rush, though I would be hesitant given the known neurochemical overlap between these two addictions.

To me, exercise was a very safe and egosyntonic addiction. Whereas random strangers would have been alarmed if I started shooting heroin (which, given my OCD-related AIDS fears would seriously never ever happen), but they told me how "good" and "dedicated" I was when they learned about just a few of my exercise habits. If exercising X hours each day makes me "good," I figured, then the actual Y hours that I do must make me "fantastic!" I wasn't going to be arrested for having gym shoes on me, or a collection of rank sports bras in my closet. I am almost pathologically risk-averse, so exercise is probably the ultimate addiction for my personality, and I fell in to the trap head-first.

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?

Though people have claimed to be "addicted" to darn near anything (herbal tea, Sudoku puzzles, hitting the snooze button, and cats are several of my non-addictions), it's pretty widely accepted that gambling is a bona fide addiction. And with any neurological talk of addiction, you pretty much have to talk about dopamine (a good if slightly technical explanation is here). Performing your addictive behaviors, or even just anticipating getting a "hit" later on, releases dopamine in your brain, which makes you feel good. So you do the behavior more, although less dopamine is released as your brain and body begin to tolerate what you're addicted to. So you increase the amount you use, and the cycle is off and running.

I have no doubt that addiction and dopamine are closely linked, and that there are also links between eating disorders and dopamine*. But new research from Natasha Schull at MIT found that people addicted to gambling aren't motivated by the "hook" of a possible big win. That may have drawn them into the habit to begin with, Schull said, but it's not what keeps them going. What keeps them going is their entrance into what Schull calls "The Zone." The zone is

a dissociative state or trance in which players lose a sense of time, space and physical embodiment, consumed totally by the spinning numbers, symbols or electronic card hands before their eyes. Because gambling machines don't require social interaction (as is the case in table games such as poker), they let people get into and stay in a state that is not dissimilar to, but far more intense than, watching TV; players describe the zone as a compelling, mesmerizing condition of intense concentration -- an almost out-of-body experience. Heavy machine gamblers come to crave this state, says Schull.

"It's about wanting to keep playing," she says. "People will actually get disappointed or irritated if they win a jackpot because it may freeze up the machine and interrupt their flow. Then they have to sit there until they lose it. Walking away with the jackpot is not an option" in their state of mind.

I've played one slot machine in my life- a nickel machine, and I put one nickel in, got nine back, and quit while I was ahead- but I am very familiar with the zone. That, to me, was one of the biggest draws of the eating disorder. I've been around the block enough times to know that losing weight won't make me happy and make me into a different person. I know that not eating will make me feel physically terrible in the long run. I know there will never be a magic weight that will finally make me feel "thin" and okay and good enough and relieved.

But damn don't I miss that zone. The blinding haze of starvation. The single-minded focus of exercising until I wanted to drop. The obsession with food. It distanced me from the world. I was interviewing for jobs several years ago and wound up the last of my friends without a permanent position. After getting turned down for a position yet again, I just thought "I've lost X lbs in the week since I last spoke with you- oh well about the job." It's partly a self-esteem thing (at least I'm good at losing weight), but the other part is the zone.

I almost feel half-dissociated when I'm in the throes of the eating disorder because my connection with reality is blunted at best and gone at worst. All that matters is eating less and exercising more. All that matters is making that number on the scale go down. So the normal, day-to-day stresses kind of fade into background noise.

Eating would wrench me out of the zone, back into the dark, noisy, smoke-filled casino that is my life. This was why I couldn't stop starving even after I reached my initial "goal weight." The zone was what mattered. If I couldn't be in the zone, then my brain tried to find any way in the book to get back there, even just a little bit. No slot machine in a casino? Well, maybe there's one in Safeway, or at the gas station, or on the internet. Maybe I can shove my snack into my pocket or lie about that bowl of cereal I ate for breakfast.

Maybe the zone is nice, even nicer than reality at times. But if all you see of life is the inside of a casino, you're missing out on a lot.

*Yes, I do have to bring everything back to eating disorders if for no other reason than I'm assuming that's why you're reading.

Back during my exercise zeitgeist, many people congratulated me on my efforts. "Wow, you're so dedicated," they would gush. I said something non-committal, usually along the lines of "Mmmm." Inside, however, I cringed. This isn't fun, I wanted to say. It's not virtuous, and I'm not dedicated. How could I be "dedicated" to something I felt obligated to do? It's like saying I'm dedicated to breathing or peeing because I do both so regularly. And it would have been just as easy to stop those as it would have been to stop exercising.

So it was with great joy that I stumbled across the following post: A healthy addiction? Not for me. You know that scene in the movie When Harry Met Sally, where Meg Ryan does that "Yes! Yes! YES!!" in the restaurant? That's kind of what I was thinking when I read this, sans drama. And yes, you can have what I'm having if you read on or click the link.

It has been nearly 11 years since I had a drink or a drug but I still struggle with my exercise addiction. Actually, I’m lying. I don’t struggle with my exercise addiction. My therapist struggles with my exercise addiction. That’s the problem. Despite years of sobriety, my addict brain can still convince me that this addiction is better than that addiction. Sure, I look a heckuva lot better than a crack addict, but we are both addicts. Any addiction - to drugs, alcohol, food or behaviors - is toxic to me, my depression and bipolar.

I like to think that today I have a handle on my exercise addiction. Back in the days when I did triathlon and ran marathons I worked out six, sometimes seven days a week. Sometimes twice a day. I spent outrageous sums of money on bikes and shoes and a ridiculous amount of time training. Just like a meth addict, I surrounded myself with other exercise addicts. Except we were the healthy addicts. Yea, right.

And I guess that's what irritates me: exercise is seen as so essentially healthy (read: virtuous, dedicated, moral) that most people cannot comprehend that one can possibly exercise too much. Yet you can. You can also exercise for all the wrong reasons. You can become hooked on the endorphin rush, become dependent on the rivulets of sweat and the sweet stale stench of the locker room.

Which is why I so treasure this one comment I got from a co-worker as we were riding the elevator down- him to the lobby, me to the basement gym.

"Whatcha doing?" he asked.
"Oh, just going for a little workout," I replied.
"That doesn't sound like fun. I'm going to visit the National Portrait Gallery," he said.
I wanted to say "Thank you for your honesty," but I just smiled and said "Have a good time!"

Both Tiptoe and Kim have already blogged on an article I read about in the New York Times about high-functioning alcoholics, but the article really hit home with me, especially this little section:

Typical high-functioning alcoholics, or H.F.A.’s as Ms. Benton calls them, are in denial about their abuse of alcohol. Coworkers, relatives and friends often enable the abusive behavior to continue by refusing to acknowledge and confront it.

“The story of the H.F.A. is seldom told,” Ms. Benton writes, “for it is not one of obvious tragedy, but that of silent suffering.”

And this is what really hit home for me: the silent suffering, the tragedy-with-a-lowercase-t. It explains so much of why I find it difficult to navigate in this world. Why I feel such gaps between my similarly-aged coworkers and myself.

Let me explain. There were definitely times when my life was abruptly and rudely interrupted when the anorexia spiraled out of control. But most of the time, it wasn't super-obvious, not even to me, how much the eating disorder had seeped into every pore. There were the food and exercise issues, yes. The tallying of every calorie. The need to workout on a certain schedule (even if said schedule wasn't excessive). The fear of restaurants. Not drinking lattes or booze because I was afraid of the calories. Yet I functioned. I graduated second in my class at college with a biochemistry degree. I've received two master's degrees.

So how could I be sick? Clearly, I wasn't that bad. I've never had a feeding tube. My weight was very low, but I've known plenty of people who weighed less.

Sarah Benton had this to say about being a high-functioning alcoholic:

“Having outside accomplishments led me and others to excuse my drinking and avoid categorizing me as an alcoholic. My success was the mask that disguised the underlying demon and fed my denial.”

Even though I'm not in denial anymore, that veneer of success also makes it hard for people to see the true depths of the problem. It's not obvious from the outside. My life has gone on, and yet there are large portions of time that I can't explain. My life has gone on, and I've yet to catch up.

Those outward vestiges of normality were almost cruel reminders to me in the depths of my illness, something so close yet so far. Although I've made great strides towards recovery, "normality" remains illusory. I do a damn good job at pretending, but that almost seems to rub it in my face that I still don't know how to relate to this world.

Therapy is going to be in my future for a long time, to try and figure out how a healthy person lives. To try and become high functioning, rather than just a high-functioning anorexic.

It's odd that it took over a century between the first recognition of anorexia as a medical illness to the first specific use of food as therapy. I'm not talking the idea that people with eating disorders ultimately need to eat (though I'm sure this, too, was revolutionary at a point in time), but that food could be medicine.

For over 100 years, this idea was really overlooked. What else could we be missing?

Although I don't have an answer specific to the ED world, the field of addition and alcohol abuse might have some interesting new leads. A new book out by a recovering alcoholic and renowned cardiac surgeon speaks of his recovery thanks to a drug called baclofen. Baclofen isn't a new drug, nor was it developed for use in addictions. The drug is actually a muscle relaxant, and works on the brain's GABA receptors to increase levels of GABA in the brain. In this manner, it provides many of the similar anxiolytic properties of alcohol in much the same way.

Several years ago, a case series (a series of case studies of addicts who were treated with baclofen) appeared in the medical journals, with seemingly promising results. Later studies--both in humans and in mice--showed mixed results. But our alcoholic cardiologist either didn't know or didn't care. Down and out and headed even further down, he got a friend to prescribe him baclofen* and found that his cravings for alcohol had disappeared.

Olivier Ameisen, the cardiologist in question, wrote a book about his experiences called "The End of My Addiction," which was reviewed on the wonderful blog Neurotopia. While the review is interesting (and provided much of the background information here), it is the ending that really got me thinking about the parallels to the field of eating disorders

The book ends in bafflement that more studies are not taking advantage of what could be the cure addiction researchers have been looking for for years.

And I also wonder, why not? The book was published very recently, and I still haven't heard of a large scale clinical trial for baclofen (though I could have missed it, of course). The drug appears relatively safe in high doses (as is known through its use in treating muscle spasms), and appears to provide relief from both the craving and the anxiety that drug users experience. What is going wrong?

Ameisen proposes one theory. He believes that, since baclofen is an old drug and no longer under patent, drug companies will never fund a large scale clinical trial. There's no money in it. He may very well be right. But I've got another theory. Most researchers who work in addiction know that addiction is a disease. It's something that you simply cannot cure through an exercise of will. It's not a problem with will power or lack of faith. And though we all know this, I wonder how many addiction researchers really believe it. A lot of the resistance that Ameisen encountered was from people who could give no real reason as to why they weren't interested in a clinical trial. Could it have been the concept of a cure? The idea that you just take a pill and make it go away? It is possible that, even though we all know that alcoholism and other kinds of drug abuse are diseases that cost the public billions of dollars per year, that society has still made up believe in will power. That we think, at some level, that addicts should suffer for what they have done. Ameisen had no suffering. He just stopped. Is our society ready to accept that kind of a cure?

I don't think that most people in the field of EDs think that people need to "suffer" because of their illness. I have yet to meet a specialist who wasn't ultimately compassionate and didn't want people to get better. However, instead of feeling that people need to "suffer," the mentality is that people need to "figure it out" in order to get better.

It's true- some people do "figure it out" and get better and if you're an adult, that's the most researched option we've got. But are we so busy trying to figure out causes and effects that we could be missing a cure that's right underneath our noses?

*I don't know what potential for abuse this drug has, but if it's being used to treat addictions, I'll bet it's fairly low. But you never know.

Eating disorder treatment isn't the only case of a revolving door- it exists for addiction treatment, too. Although I don't honestly think an eating disorder is an addiction in the strictest sense of the word (you can live without heroin, you can live without blackjack, but ya gotta eat), there are similarities too poignant to ignore. Both illnesses are relatively poorly understood. Both illnesses ruin lives when they don't outright kill or maim. And both illnesses desperately need more effective treatments.

In the New York Times today, an article from the ongoing series "The Evidence Gap" appeared called "Drug Rehabilitation or Revolving Door?" which looked at the dearth of evidence-based treatments for addictions.

Every year, state and federal governments spend more than $15 billion, and insurers at least $5 billion more, on substance-abuse treatment services for some four million people. That amount may soon increase sharply: last year, Congress passed the mental health parity law, which for the first time includes addiction treatment under a federal law requiring that insurers cover mental and physical ailments at equal levels.

Many clinics across the county have waiting lists, and researchers estimate that some 20 million Americans who could benefit from treatment do not get it.

Yet very few rehabilitation programs have the evidence to show that they are effective. The resort-and-spa private clinics generally do not allow outside researchers to verify their published success rates. The publicly supported programs spend their scarce resources on patient care, not costly studies.

And the field has no standard guidelines. Each program has its own philosophy; so, for that matter, do individual counselors. No one knows which approach is best for which patient, because these programs rarely if ever track clients closely after they graduate. Even Alcoholics Anonymous, the best known of all the substance-abuse programs, does not publish data on its participants’ success rate.


“What we have in this country is a washing-machine model of addiction treatment,” said A. Thomas McClellan, chief executive of the nonprofit Treatment Research Institute, based in Philadelphia. “You go to Shady Acres for 30 days, or to some clinic for 60 visits or 60 doses, whatever it is. And then you’re discharged and everyone’s crying and hugging and feeling proud — and you’re supposed to be cured.”

He added: “It doesn’t really matter if you’re a movie star going to some resort by the sea or a homeless person. The system doesn’t work well for what for many people is a chronic, recurring problem.”

And the same could be said for eating disorders. We need to know more about the cause so we can design better treatments. But we also need the treatments NOW, need to do the best with what we have, and not just to be "cost effective." Of course good treatment would ultimately cost-effective, but we shouldn't be looking for evidence based treatments just to save money. We need treatments that work in a RELIABLE and EASILY REPLICATED manner.

When practiced faithfully, evidence-based therapies give users their best chance to break a habit...“Our goal at CODA [a Portland, OR drug treatment program] is to create a system of care that uses evidence-based practices at just the right dose and just the right time,” Mr. Hartnett said. “As with many chronic diseases, figuring out dosage and timing are critical.”

A true statement if ever there was one. Note that this isn't the ONLY chance, just the BEST one.

This isn't to say throw the baby out with the bathwater, yet for a clinician to be told "The way you're doing things is wrong," might not be the easiest of pills to swallow.

"To complicate matters in Oregon, the state mandate has stirred a kind of culture clash between those who want reform — academic researchers, state officials — and veteran counselors working in the trenches, many of whom have beaten addictions of their own and do not appreciate outsiders telling them how to do their jobs."

Oregon's solution? One way to do that, some experts now believe, is to combine evidence-based practice with “practice-based evidence” — the results that programs and counselors themselves can document, based on their own work...“We basically gave them a list of evidence-based practices and told them to pick the ones they wanted to use,” said Jack Kemp, former director of substance abuse services for Delaware, in an interview. “It was up to them to decide what to use.”


What a novel idea- and how wonderful it would be to see this applied to eating disorders.

I'm aware that I pasted large chunks of the original article in the post, but the whole thing is well worth a read. Please share your thoughts in the comments section.

One of the characteristics of anorexia, says researcher and clinician Daniel LeGrange, is not just starvation; rather, he says, it is starvation in the midst of plenty. While one theory is that anorexia may have evolved as an adaptation to allow humans to better withstand famine, most modern cases of anorexia occur where food is abundant. In that sense, perhaps anorexia can be understood as self-administered starvation.

Which is where a recent study on cocaine addiction comes in.

A recent study from the University of California, San Francisco found that self-administered cocaine had different effects on dopamine receptors than a passive infusion of the drug.

Says a press release:

...cocaine-associated changes were due to an associative process and not just to the pharmacological effects of the drug. "We suggest that neuroadaptations induced specifically by drug self-administration may form a powerful 'memory' that can be activated by drug-associated cues," explains coauthor Dr. Billy T. Chen.

How self-administration of a drug but not a natural reward can elicit enduring changes within the brain remains a mystery. "Future studies are required to identify the exact mechanisms through which drugs of abuse alter neural circuitry that is normally accessed by naturally reinforcing events but is usurped by cocaine to persistently cement these synaptic adaptations, perhaps ultimately leading to pathological drug-seeking behavior," concludes Dr. Bonci.

While anorexia is not cocaine addiction, the illness does involve differences in dopamine levels and receptors in the brain. Perhaps part of what cements anorexia (besides the starvation itself) is the self-seeking behavior. The "benefits" of starvation to the sufferer are reinforced each time he or she skips a meal, binges, purges, and overexercises.

From an evolutionary standpoint, the survival of the human species means that people will need to begin eating after a famine has passed. The ability to withstand starvation may have descended from this. But anorexia nervosa may cement itself into a life-threatening illness when a person begins to starve while food is abundant.