My friend Kathleen MacDonald shared this on Facebook earlier today, and she graciously gave me permission to share it on my blog. I hope you enjoy.


‎"So how did you turn things around?" is one of the most common questions I get about my recovery-process. I wish there was an easy/short answer...but there isn't. (don't worry --this won't be one of my lonnnnnnnnnnnngggggg-winded status to detail the answer) ~ There were several key components to my final recovery process that led to me becoming recovered...here are a few:

a. I got serious about nutrition and I stopped making me the "exception" to needing to eat
b. I got serious about gaining body fat
c. I learned to be comfortable feeling uncomfortable and I didn't fall back into the disease every time my body image felt like hell or my guts distended/I felt pregnant
d. I got serious about the fact that every purge could be my last
e. I got serious about the fact that it wasn't safe to exercise (I ended up taking nearly 2 years off from exercise --which was really hard to do) when I was under-nourished and under-hydrated
f. I realized that I needed to 'over-nourish' my body in an effort to replenish and repair all the damage done (even if my bloodwork was 'normal')
g. I kept Kitty Westin and Ron & Sally Crist George in my heart/prayers ever day 
h. I put God in the center of my recovery-process (along with nutrition)
i. I did not listen to the doctors who told me that I had to give up gluten and dairy b/c I had "intolerances" -- of COURSE I had intolerances to those foods...I had intolerance to most foods b/c my body was so screwed up from all the years of 'dieting'
j. "suicide is not an option" became my mantra -- no matter what, suicide is never the answer
k. I disconnected myself from unhealthy relationships
l. Recovering became my number one focus --above school, fun, relationships, etc... First Job = recovering
m. I dared to dream that RECOVERED existed and I sought after it with all my heart (it exists, trust me!)
n. I put the emotional stuff on hold until my brain was better healed - (and guess what --after my brain was healed and I was thinking clearly for the first time in 16 years, I realized that the emotional stuff that had caused me so much pain and trauma...it wasn't as bad as my ED brain had convinced me...and I was able to heal from it vs. sink into deep despair)
o. I got rid of life-expectations that I had for myself (ie: I must have my Ph.D. by the time I'm 30)...and I just focused on recovering...and I trusted that Ph.D programs would still be available when I was recovered ;-)
p. I stopped trying to help others and I learned to 100% focus on me
q. Gretz, the Super Setter --enough said.
r. I learned to forgive myself
s. I ate thru the pain
t. I stopped purging
u. I stopped believing that I was ugly
v. I stopped believing that my body is less-than-beautiful when I am healthy
w. I stopped thinking that cellulite is ugly
x. I got rid of my scale
y. I healed my body image issues thru nutrition, 'sitting with it', and thru learning to see myself and everyone else thru the eyes of God --which means that I see every single human being as beautiful.
z. I never gave up on the enigmatic power of Hope.

My new friend Adam Lamparello posted the following on his Facebook page:

One thing that many people discuss when it comes to eating disorders is the issue of co-morbidity, that is, many people with anorexia, bulimia or any other eating disorder also struggle with depression, anxiety, obsessive compulsive disorder, etc. I agree with this, in part because I had the same problem and the research supports this fact. But now, research is showing that eating disorders, and factors such as low-self esteem and extreme sensitivity, may have biological roots. In other words, we may be pre-disposed to developing an eating disorder and be predisposed to having the factors that are common to causing the development of an eating disorder (although there are many other factors unique to the individual). There's one thing that I do disagree with, though, and that seems to be that ED experts separate the issues of eating disorders and depression, anxiety, OCD, etc. Hence the term co-morbidity. I would hypothesize that anorexia and bulimia can actually cause depression and anxiety disorders in an individual who would not necessarily be pre-disposed to these conditions. At the very least, eating disorders can make these conditions considerably worse in those individuals that are predisposed to mental health issues or would not necessarily develop such issues based on pre-disposition alone. In fact, I think they are intertwined, especially when we eventually know the extent of their biological roots.

Basically, right on.

A lot of the personality and eating disorders research seems to indicate that many sufferers have a cluster of different personality traits that seem to predispose them to EDs. The two general clusters tend to be over-controlled, anxious, and perfectionistic, and the other is impulsive, anxious, and novelty-seeking. Not surprisingly, these personality clusters also predispose people to co-occurring conditions like depression, OCD, and personality disorders.

I do think that some people truly have co-occurring conditions. I've had episodes of severe depression, anxiety, and OCD that were totally separate from my eating disorder. But the eating disorder also amplified my obsessive, anxious, perfectionistic temperament, and not in a good way. You can't tackle co-occurring conditions if you're not also tackling the eating disorder. As well, regular nutrition generally tends to improve co-occurring conditions. For some people, what looks like depression and anxiety and whatever else are actually side effects of starvation.

The truth is that no one really knows whether things like OCD and depression are part and parcel of an eating disorder or they exist alongside of it but totally separate. Another example would be red hair and green eyes--I am proud owner of both these traits. Although they do frequently appear together, plenty of people with red hair have blue or brown eyes, and my mom has green eyes and blonde hair.

As well, no one knows at exactly what level these temperament traits become pathological. At what point do they cease to become odd quirks and start to be something that needs treatment. So no one really knows.

It's a question I wish more psychologists and researchers took time to ask.

Men get eating disorders, too. A British organization by the same name has a website and Twitter account by the same name. Eating disorders information can be found at the website for the National Institute of Mental Health, and also on the website for information on women's health. It implies that eating disorders are just a women's issue.

As the Kartini Clinic blog pointed out last week, one of the very first medical descriptions of anorexia was of an adolescent male. In 1689, believe it or not. So the idea that eating disorders are "just" women's issues is actually quite wrong.

The problem is that after Richard Morton first described anorexia in 1688, later medical doctors lumped anorexia in with "hysteria." Hysteria is derived from the Greek word for the uterus (which is why you get a hysterectomy), which means that men automatically can't be "hysterical" in the nineteenth century, technical usage of the word. Which is where we started to go wrong.

Later conceptualizations of eating disorders continued to exclude men, because eating disorders were seen as a female over-concern with one's looks, or a diet gone wrong. Men, it seemed, didn't face these pressures and/or were too smart to fetishize the size of their asses. Since men didn't face the body image pressures that women did, men couldn't get eating disorders.

It's bollocks, by the way. If you're human, you can get an eating disorder.

I'm blogging about this not just because I've been reading stuff about eating disorders in males, but also because I got a press release emailed to me this morning about a symposium on male eating disorders at the 2012 IAEDP conference this spring.  The tag line was:

Our latest news shares the sad and startling fact that one in three men are willing to shorten their lifespan just for the sake of better meeting society's image of the "ideal" man.

Huh?

I mean, there are just so many things wrong with this. First of all, eating disorders have existed long before current body ideals evolved, so that can't be the cause. Second, an eating disorder isn't being "willing to shorten your lifespan." That's like saying someone is willing to develop cancer so they can lose weight from chemo. Eating disorders aren't choices. They aren't about vanity or looks. They're a real biologically-based illness that kills, not because vain and vapid people of all sexes and genders are too self-absorbed to stop harming themselves, but because they have an illness that we generally suck at treating.

Also, I'm not sure of the scientific validity of a hypothetical "would you rather" question in assessing body image issues or eating disorders in any population. Nor are people with eating disorders actually making these decisions. Like I said, it's an illness, you idiots.

Of course, what I got was a press release and promo information. I don't know exactly what the presentation is going to contain. The email I got did say that they were also premiering a male-specific eating disorders assessment, which could be a very good thing. I haven't seen it, so I can't say for sure.

It's just that perpetuating these myths about what causes eating disorders doesn't do anyone any good in the long run. Yes, issues of eating disorders in males does need more attention, but could we at least get the facts right first?

When I went on vacation last week, I knew there was a lot of activities I would want to do.  I spoke with my therapist about being more active than usual, which she said was fine, as long as I ate more to compensate.  So I ate a bit off the meal plan, and all worked out well.

We've discussed this in the past, the idea of eating "extra."  That is, eating outside of scheduled snacks and meals, or eating more food than "required" at those times.  Not surprisingly, this freaks me out.  I've never been a rule-breaker.  The very idea terrifies me.  Part of it is the sense that the rules are the rules, and you don't break the rules.  If I do think a rule is silly, I often am too anxious to go outside the prescribed letter of the law anyway.  I rely on rules (many of them self-imposed, but rules nonetheless) to help me cope with anxiety. Breaking a rule is anxiety-provoking in and of itself.  Breaking an ED rule is even more so.

But my therapist raised a really good point.

It's not "extra" if you're hungry or you've been more active.  That food is necessary.

I've often complained to her about how horrible I feel when I eat food that isn't on my meal plan*.  And almost every time, my therapist said that my weight stayed the same and so my body needed every calorie.  This meant that those "extras" weren't extra at all--they were more like little "necessaries."

Oh.

An extra is eating some dessert because it looks good, even though you've just had dinner and aren't all that hungry.  It's finishing all of your favorite entree at your favorite restaurant because you love it, even though you started feeling full near the end.  That sort of thing.  Eating in response to hunger is never "extra," even though the food may not appear on any piece of paper.

The obvious solution would be a new rule to "eat when hungry."  Except implementing this rule means changing the old rule of "eat what's on the plan," which means facing the anxiety of rule-breaking AND change, neither of which I do well at.  I also mistrust hunger signals and never quite know (unless I'm ready to gnaw on my neighbor's arm) if I'm really hungry or just think I am or if what I think might be hunger means I should eat something or get something to drink or just suck it up.

Quite a quandry.

*I'm guessing right now that I'm going to get comments saying I should ditch the meal plan.  The problem is that I would likely undereat without the guidelines. My instincts on what I "need" to eat aren't the greatest. A meal plan can be a double-edged sword, but I think the positives outweigh the negatives at this point.

Last week, the American Medical Association released a policy statement about Photoshopping models and eating disorder prevention.

The statement:

Advertisers commonly alter photographs to enhance the appearance of models' bodies, and such alterations can contribute to unrealistic expectations of appropriate body image – especially among impressionable children and adolescents. A large body of literature links exposure to media-propagated images of unrealistic body image to eating disorders and other child and adolescent health problems.


The AMA adopted new policy to encourage advertising associations to work with public and private sector organizations concerned with child and adolescent health to develop guidelines for advertisements, especially those appearing in teen-oriented publications, that would discourage the altering of photographs in a manner that could promote unrealistic expectations of appropriate body image.


"The appearance of advertisements with extremely altered models can create unrealistic expectations of appropriate body image. In one image, a model's waist was slimmed so severely, her head appeared to be wider than her waist," said Dr. McAneny. "We must stop exposing impressionable children and teenagers to advertisements portraying models with body types only attainable with the help of photo editing software."

And if the AMA had left out the mention of "eating disorders" at the end of the first paragraph, I wouldn't have had anything to say except to nod my head in agreement.  Because the alteration of images is appalling and imappropriate and, indeed, harmful.  The problem is the link to eating disorders.  The AMA said there was a "large body of research" linking media exposure to eating disorders.

So I went looking to see if I could find this large body of research.  I went to PubMed and searched for "eating disorders media" and indeed, I pulled up 264 studies on the subject.  But if you read the studies more closely, you'll see that there's lots of links between "disordered eating" and "eating pathology" and "body image dissatisfaction" and media exposure, but there's very little mention of linkage to outright, diagnosable eating disorders as spelled out by the DSM-IV.  One study did actually say that "media contributes to the development of eating disorders," but when I looked at the studies cited, all I saw were examples that linked media exposure to disordered eating.

A lot of the media coverage of the story has said that Photoshopped images "promote anorexia."  I'm not entirely sure I understand what that means.  I think I know what they're getting at--that looking at these images make you more likely to develop anorexia--but there's no actual evidence that this is true (at least, none that I could find).  We don't think ads for disinfectant somehow promote OCD.  We also don't think that those Bluetooth headsets promote schizophrenia because it looks like you're talking to yourself.

I think the big difference is that people don't think they know what it's like to have schizophrenia because they've been paranoid at one time or another, or that they've had a rather animated conversation with themselves.  But people do think they know what it's like to have an eating disorder because they've dieted and asked their husbands if these jeans make their butts look big. 

It's a common mistake, confusing disordered eating and eating disorders.  Many men and women are unhappy with their bodies and are on a diet.  People with eating disorders also often express extreme body dysmorphia and restrict their food intake.  They do look alike on the outside, but the internal experience is very different.  Dr. Sarah Ravin summarizes the difference between disordered eating and eating disorders as follows:

Disordered eating is very widespread in our country, especially among women. I define disordered eating as a persistent pattern of unhealthy or overly rigid eating behavior – chronic dieting, yo-yo dieting, binge-restrict cycles, eliminating essential nutrients such as fat or carbohydrates, obsession with organic or “healthy” eating – coupled with a preoccupation with food, weight, or body shape.


By this definition, I think well over half of the women in America (and many men as well) are disordered eaters.


The way I see it, disordered eating “comes from the outside” whereas eating disorders “come from the inside.” What I mean is this: environment plays a huge role in the onset of disordered eating, such that the majority of people who live in our disordered culture (where thinness is overvalued, dieting is the norm, portion sizes are huge, etc) will develop some degree of disordered eating, regardless of their underlying biology or psychopathology.


In contrast, the development of an eating disorder is influenced very heavily by genetics, neurobiology, individual personality traits, and co-morbid disorders. Environment clearly plays a role in the development of eating disorders, but environment alone is not sufficient to cause them. The majority of American women will develop disordered eating at some point, but less than 1% will fall into anorexia nervosa and 3% into bulimia nervosa.

I think it's great that the AMA is trying to protect children and adolescents from companies that would turn actual women into bobblehead models (the woman in the Ralph Lauren ad looks a bit like a bobblehead since her head is so disproportionately large compared to her body).  Our ideas of what "normal" and "healthy" look like are disorted and it is harmful.  On that subject, the research is clear.

Are you the parent of an adult child with an eating disorder? Run, don't walk to this blog post by one of my favorite blogs, F*ck Feelings.

Actually, I'll save you the bother of clicking and just post the whole thing in its entirety below (the question from the parent is in italics. Everything else is from the blogger/psychiatrist):

People like to turn to an authority when they’re helpless, and if that helplessness only applied to 911-like situations, there would be no problem. For problems that don’t involve theft or fire but sadness and family, however, authority is useless; sure, doctors like me can give advice, but until medical schools start borrowing from Hogwarts’ curriculum, the best resources you have are your own. The sooner you realize that, the sooner you’ll learn to draw on your own authority to come up with the best possible management plan and execute it with confidence. You are your own best first responder.


I need to find a doctor who will tell my daughter she needs to take her medication. She’s always had a problem with depression, and she did well in high school when she took antidepressants. Now, however, she’s 24 and very reactive to however she’s feeling, whether it’s not getting out of bed, or not working, or feeling dizzy and deciding it’s the medication and stopping it. My husband and I can’t get her to stick with anything, and she won’t listen to us in any case, so our goal is to get you, or some professional, to tell her what she needs to do.



Whenever parents want a doctor to tell their kid what to do, you can be pretty sure they’ve lost faith in themselves and overestimated the power of communication/a medical degree.

And no, it doesn’t matter how old the kid is or how many Harvard degrees the doctor has; the doctor doesn’t have more power than the parents, no matter how powerless the parents feel.

In your case, I don’t know whether your daughter can be induced to take her medication, but I do know that she’s not going to be persuaded by the authority of a doctor at the age of 24 if her own experience and your words haven’t done it by now.

The probable reason for her unresponsiveness, by the way, isn’t stubbornness or a lack of respect, but a lack of control over her own impulsivity (probably enhanced by depression). In other words, it’s not clear she can make herself take medication regularly, even if she sincerely believes she needs it. At some point, other impulses take over, like the impulse to stay in bed indefinitely.

Fortunately, even though persuasion is probably useless, you have other tools that a mere doctor can’t touch. You can access them if you believe you know what your daughter needs, regardless of what she has to say about it.

For instance, if you believe that she needs to get up early and follow a daily activity regimen, then let her know that’s what you’ll pay for. If she says she’s too blah, tell her you know it’s hard, but she needs to try, and that she might be able to do it if she puts together a schedule and asks friends to help her keep it.

If she argues that she can’t do it until she feels better, tell her that you don’t know when she’ll feel better, so she’d better start trying to keep busy now, and maybe that will help her feel better later. Your tone should say that you believe what you believe, and there’s no point in arguing.

If she tells you that you don’t know what she needs, tell her that you’re the mother and you have a good idea what she needs. Don’t ask a doctor to be the authority– get whatever information you need from the doctor, and then assume you’re the authority. At 4 or 24, your kid needs to hear the same thing; you’re the mommy, that’s why. End of discussion.

If your incentives don’t work, don’t blame her or yourself, because, again, you don’t know whether she’s too sick to have the control she needs. By putting a priority on self-control, however, you provide her with a blueprint for moving forward that is not reactive to negative feelings or thoughts or painful side-effects.

You’re urging her to embrace goals that arise from her values and that she can stick with, regardless of how she feels or how much she accomplishes. Knowing medicine isn’t as important as knowing your daughter and what’s best for her. If she won’t listen to me, you can, and I’m telling you you’re the most qualified professional for the task.

STATEMENT:
“I’d like to think my daughter could respond to persuasion from someone she respects, but I suspect it’s not true. I’ll push her towards doing as much as she can, regardless of how she feels, and hope that incentives for good habits will take over where persuasion has failed.”

Excuse me while I go clone this guy millions of times over so that a) he can be all of our doctor and b) so that we can have him as our very own Psychiatrist Pocket Pal^TM.

It's nice to think about preventing eating disorders.  I'm not saying we can't do it or we shouldn't try.  But I'm wondering how teaching kids about "loving your body" and the dangers of eating disorders is actually going to help.

In a recent Huffington Post article, therapist Judith Brisman writes:

•Talk about eating disorders and how dangerous they are. Talk about it in the same way you talk about lung cancer and smoking -- or death and drunk driving. It's that dangerous. It can't be ignored.


•Help your kids pay attention to their inner life. What are they feeling inside when they turn to the third batch of cookies, or when they are skipping breakfast and lunch? Be genuinely curious about their fears, thoughts and worries about their body. And educate them! They may not know that skipping breakfast and lunch disrupts metabolism.

•Help your kids be responsible for what they are eating. Allow them snacks. For example, it's okay to eat cake -- but how many times a day? And what should portion size look like? Talk, be curious, instruct and pay attention. Kids need to know that if they get too skinny or become anorexic, they won't be able to be in the school play or on the hockey team. Kids should be as scared of anorexia, binge eating and bulimia as they are of smoking and drunk driving. They also should know that there are many things that can be done to help if they worry they are in trouble with food.

I don't think that these things are bad.  Open lines of communication between parent and child are very important.  And I do think that kids should be taught about eating disorders the same way they are taught about smoking, drunk driving and cancer.

My question is this: do we know that this will actually prevent eating disorders?

I'm guessing that most people who develop an eating disorder today probably know what one is.  I knew eating disorders were dangerous before I got sick, and it didn't really stop me.  One, I thought it would never happen to me. Two, I didn't realize I had anorexia until I was already stuck. 

I wish more kids (and adults!) were taught about the dangers of dieting and that "healthy eating" can go too far.  I want more people to know about exercise--too much and not enough.  I can believe that these things might help.

But explaining to someone how dangerous eating disorders are isn't going to prevent someone from getting sick.  It's like telling someone that cancer can kill you and expecting that this will make cancer rates go down.  It's a nice thought, but that's not how cancer works.  And that's not how eating disorders work, either.

Eating disorders are baffling and scary, and it's probably nice to think that if we just don't complain about our butts and if we tell little Susie and Sammy that EDs can kill, then surely they won't be stupid enough to get sick.  After all, my mother once told me (in all seriousness) that she never thought I would develop an eating disorder because I was smarter than that.  As in, I knew it was dangerous so why would I "dabble" in anorexia?

Because I didn't know I was dabbling in anorexia when I first got sick.  I just wanted to eat "better."  I was actually trying not to get anorexia.  It happened all the same because an eating disorder isn't a choice.  It's not logical.  It's an illness. 

Writer Naomi Wolf was the keynote speaker at NEDA this year, and I honestly wasn't sure I was going to hear her speak.  Not because I'm anti-feminist (I'm not) but because I've read her book "The Beauty Myth" and I didn't find it that relevant to my own experience of an eating disorder.  I'm glad I went as a) it wasn't as bad as I feared and b) I found that many people had a similar response to what Wolf had to say.

I've heard Wolf speak before, and she is a phenomenal, engaging speaker.  She's super-articulate, very intelligent, and she knows her stuff.  I very much respect her and what she has to say.

However...

Although I think our cultural ideas and beauty obsessions and diet mentality are absolutely toxic, I don't think that if you eliminated them, you would eliminate eating disorders.  Most women feel bad when they're looking at Photoshopped models.  Most women diet at some point.  Most women don't have eating disorders.

(Not to mention, what about men?  What about people who live in cultures when thin isn't overvalued?  What about people with non fat-phobic anorexia?)

It's not uncommon for an eating disorder to start with an effort to "tone up" or "lose a few."    Yet once the disease process starts--once it kicks in--appearance is the last stinking thing most people with EDs are really thinking about.  People told me that my ED was making me look atrocious.  I was aware, on some level, that they were right.  By that point, the ED had a life of its own.  I was terrified of eating.  Even if it didn't have calories and exercising didn't burn any of them off, I would have still felt compelled to starve and exercise.  I couldn't stop.  That's why it's an illness.

I'm aware that the only evidence based prevention programs for eating disorders have focused on improving body image, and I'm not saying they don't work.  The research literature shows they do work.  But in a survey of 6000 eating disorder sufferers, no one said that their eating disorder had anything to do with vanity or cultural ideas (I heard this in a presentation by Susan Ringwood, the CEO of the UK charity B-EAT).  They did say that cultural ideals made it harder to recover, something I definitely endorse.

Eating disorders existed before thin was in, and they will probably exist after Size Zero seems as antiquated and misguided as chastity belts and foot binding.  The cultural language of fat and thin and dieting are what we have to put our experience into words.  They are how we frame what is happening to us.  People in the Middle Ages framed anorexia has an effort to be more spiritual.  Now, we look at it as an effort to be thinner or look like some supermodel.  But the way we make sense of an illness is different than the illness itself.

It just fundamentally bothers me that fighting eating disorders is seem as (in large part) fighting the fashion and cosmetics industry.  They use our obsession with being thin and such to sell products, it's true.  They make lots of women feel insecure about their looks, and then go on whackjob diets.  The body dysmorphia that accompanies an eating disorder isn't just a really bad version of wondering if these pants make your thighs look fat.  Being beheaded isn't just like a really bad paper cut, either.  An eating disorder isn't a really extreme diet.  It might look like that, but it's fundamentally different.

Wolf mentioned nothing about underlying vulnerabilities like anxiety and depression to eating disorders.  She did say that restricting in and of itself is crazy making, which is good.  Although she said that "parents don't cause eating disorders," she also said that her own mother's bitching about her thighs primed her for anorexia.  None of her other siblings developed an eating disorder, yet I'm sure they all heard the kvetching and comparing.  Why Naomi?  Why only her?  It's fundamentally not okay if your mother is diet-obsessed and tells you you're too fat.  Not okay.  And that sort of environment is certainly conducive to the development of an ED, but it's impossible to say that had this person grown up in a different environment, they never would have developed an eating disorder.

It was...frustrating at times to hear no mention of science and biology.  My friend Sarah Ravin asked Wolf afterwards why there was no mention, and Wolf said "I don't really do that science stuff."  I understand that science might not be everyone's little pet, but seriously?

The emphasis on beauty images only reinforces the idea that EDs are an expression of vanity, or just a bunch of beauty-obsessed kids who need to stop reading magazines.  And they're not.  Our focus on this does everyone a disservice.

One of the hardest things for me to adjust to in recovery was all of the spare time and energy I had.  When I was in the depths of ED, I spent all my awake time perseverating about how much I ate, how much I exercised, what I weighed, and how much I hated life.  I could distract myself for brief periods--maybe for a few pages of an unusually good book or during a movie scene--but the ED always intruded.  This dragged me back to going over and over these things in my head.  Literally, these thoughts were my life.

As they receded, I often felt my brainpan was going to collapse without the constant pressure of those thoughts zinging around.  The obsessive thoughts lessened somewhat as I reached a healthy weight, but they still occupied freaky amounts of my time.  I didn't enjoy obsessing about every little thing, but I didn't know what else to do.  One of the things that left me so vulnerable to relapse was the fact that I didn't have anything to take the place of the ED that had occupied my thoughts for so long.

I found writing to be so helpful not just because it helped me sort through my thoughts, but because it provided me with something to do.  For the first time, I had something much more interesting, enticing and absorbing than the ED crap to think about.

I slowly began to find things that were not only more interesting to think about but could also be totally absorbing when I actually did them.  That's what I loved about mountain biking- I literally could not think of anything besides not crashing.  I hated the constant threat of danger, but I loved the challenge and the total mind-absorbing nature of it.  It's one of the main reasons I fell in love with cycling- I could daydream but the task at hand still demanded almost all of my attention.

I still struggle to clear my head while writing at times.  I'm aware that this is pretty normal, but I get a little more peeved when it's ED stuff creeping in rather than more normal, I-need-to-run-the-dishwasher kind of stuff.  And if writing doesn't do the trick (and I have some free time, which is becoming an increasingly rare phenomenon!), I can get involved in a good book as reading is another major passion of mine.

Finding my passion for writing didn't enable me to recover--there was a lot of hard work and therapy and facing my fears about food one at a time and meal after meal after meal.  But it's one of the best motivations to stay recovered.  Then I can actually get absorbed into books and projects and bike rides.  When I'm malnourished, all I can think about is food.  Now that my brain and body are (mostly) healthy again, I can focus on bigger and better things.

There was an interesting thread I found on a discussion board that was discussing why medical professionals were so obviously not clued in about eating disorders. There are issues of insurance companies (in the US) and national healthcare rules (in Canada, the UK, etc), but that's not exactly what I'm getting at. It's that most medical professionals just don't get it--even, occasionally, those that say they "specialize" in eating disorders.

I can think of several reasons this might be:

1. Ignorance. Some doctors really truly don't have a clue. The more dangerous (and common) situation is where the doctors think they have a clue, but they really don't. We can break this down even further: there are those medical professionals who have no idea that they're out of their league and there are those won't admit that they're out of their league.

It's interesting, because I really respect a doctor who can say "You know, this really isn't my area of expertise, but let me find someone who can help you better." I'm guessing it's hard for someone (a doctor in particular) to admit they don't know everything, but I can tell you that I respect you more because of it.

2. Powerlessness. Many things that GPs and PCPs are trained to treat basically involve telling a patient what to do or giving them some medicine, and then the problem is solved. Even when other chronic conditions aren't quite this straightforward, there's an obvious path to take. First you do A, then you try B, then C. So some doctors will do the old "have a sandwich" routine because it's the kind of thing that works with other illnesses.

But the problem with an eating disorder isn't actually eating the sandwich. It's getting yourself to eat (and digest) the sandwich. Not that EDs aren't frequently accompanied by GI issues, but I can guarantee you that most ED patients have thought about eating a sandwich. It's the fears of what might happen if I eat that sandwich that get most patients, and I don't think that's really understood.

The other thing that I don't think many doctors realize is that EDs really aren't like other illnesses. The reason why?

3. Wrong assumptions. When someone gets sick, they usually want to get better. The problem with eating disorders is two-fold: many patients don't recognize there is a problem. And when they do, there are often serious issues with the follow-through. Sometimes motivation fades. Sometimes you're just lying to get the hell out of the office. Sometimes the patient underestimates just how hard it's going to be. Or they don't grasp the depth of the problem ("My eating disorder really isn't that big of a deal.") Most medical professionals don't get this. They don't understand why someone would engage in ED symptoms. So they assume that you're ready and willing to stop--which isn't always the case.

4. They take the patient's lead. This isn't always a bad thing. I think it's good for doctors to take a patient's lead on interaction style, what types of treatments work best, that sort of thing. But when a patient really isn't all that distressed by something that is killing them, the doctors often figure that it must not be that serious.

(I've had this problem with depression simply because I'm not overly demonstrative of my emotions, and I have a very dark sense of humor anyway. So I can be severely depressed and making smart ass remarks...only I really do mean them.)

5. The media. Mostly when you see EDs in the media, you see the most extreme cases. So when someone comes into your office whose weight isn't as low as that chick on TV last night, or who doesn't binge and purge as frequently, it's much easier (though no less irresponsible and stupid) to write that patient off.

6. Over- and under-reliance on labs. Many people with eating disorders can be severely ill and still have normal labs. On the other hand, people can look rather healthy and have totally whacked out labs. But since their weight isn't really low, it can't be that bad. If their weight is low, but their labs are normal, then they're not that sick.

7. Over-reliance on weight. This one pretty much explains itself.

8. Obesity hysteria. When all the messages you hear are to make sure that your patients aren't too fat, you're probably not looking to see if some of them are too thin. A doctor frequently encourages someone's weight loss efforts because they're thinking "At last! Someone I don't have to lecture about Cheetohs!" Or they overlook weight loss in a growing child because they're not yet "underweight" even though the weight loss is dramatic, marked, and takes the person off their growth curve.

9. They just don't want to deal with it. I'll be the first to admit that I'm probably not the easiest patient to have, especially when I was ill. I'd skip appointments or show up and deliberately blow off your advice. I wasn't aware that I had a problem, and then a crisis would arise and all hell would break loose. I don't envy my doctors and therapists, which is one of the most obvious reason why I don't want to be a doctor/therapist myself. But tough patients come with the territory. It's part of the game, and it's someone's life that you're gambling with.

Why do you think so many medical professionals just don't get it? Share in the comments, but I ask that this not become a comparison to see who was the sickest. You don't need to say how many times a day your purged, or what your weight/BMI was. That's not the point. What I'm curious to see is what have your experiences taught you about why so many doctors are so clueless about eating disorders.

I love the blog F*ck Feelings. It always provides a great perspective and very useful advice for dealing with what the authors call "the shit sandwiches of life" (their advice: ask for ketchup). They've never really addressed eating disorders, and I was always curious to see how they handled the subject. One of the most recent blog posts gave me my answer.

A woman had written in about being very dissatisfied with her weight, and asking why she was having these problems if she was already on the thin side.

Dr. Lastname ("because doctors always go by their last names") had this to say:

Most people aren’t happy with the way they look or how much they weigh, and all people spend at least a little time each day being unhappy, but many still manage to live normal, albeit slight chubby/grumpy lives.

As to the source of your insecurities, your guess is as good as mine and the many other scientists, clinicians, and desperate-for-a-topic writers who explain this phenomenon. It could be your ex, or it could reading too much Cosmo.

These experts assume, for the most part, that you wouldn’t be so self-critical if you didn’t listen to magazines, celebrities, or your critical-yet-well-meaning grandmother, and just believed in your self. They tell you that self-esteem will conquer all. Of course, they’re wrong.
There’s lots of evidence that self-hating body thoughts can happen to people with perfectly good self-esteem, nice families, and normal bodies. Instead of obsessing about why you feel this way the same way you obsess over calorie counts, stop and ask yourself, first, whether these thoughts are doing you much harm.

I know they’re causing you pain, but ask yourself whether they’re affecting your health or relationships. Right or wrong, you can think you need to lose a few without hiding major parts of your personalities and or being a bad friend or parent.

If you think your body-hate isn’t doing too much harm, try ignoring it. Certain kinds of psychotherapy may help, but watch out if you find yourself becoming more self-obsessed and blaming yourself for not getting better. The mark of good psychotherapy, like good coaching, is that it gives you ideas and motivation for managing a problem without increasing your expectations of control.

If body-hate is hurting your health or relationships—if you purge, have become anemic, or acquired any number of the dire symptoms that come with an eating disorder—assemble a treatment team, including a primary care physician, a psychiatrist and dietitian, and don’t hesitate to put yourself into an around-the-clock “eat-your-food” camp if it’s necessary. It can save your life.

In any case, don’t pin your hopes and self-esteem on self-control, or self-hating thoughts will just get worse. If you make it your job to keep trying and regard the illness as you would the weather, it can’t touch your sense of who you are.

You need never see yourself as a food nut or anorectic; you’re simply a person with eating issues, which puts you in the same camp as 90% of the population. You might feel like shit, but you are truly not alone.

Aside from their perspective on intensive treatment (an around-the-clock "eat your food camp" is an apropos enough descriptor), their benchmarks for determining the difference between disordered eating and eating disorder is pretty darn accurate. Because so many people are obsessed with food and weight, it's often hard to determine where this cultural obsession leaves off and where an eating disorder begins. If your obsessing about food, weight, exercise, etc, are causing any health problems (purging, anemia, marked/unhealthy weight loss) OR if these obsessions are hindering other areas of your life, then you've got a serious psychological problem. Not that you can't or shouldn't address disordered eating, but feeling like crap after reading Cosmo is not, in and of itself, an eating disorder.

It should, however, be a really big sign to stop reading magazines that make you feel like crap.

What do you think of "Dr. Lastname's" assessment of eating disorders in general and this woman in particular? Share away in the comments!

I blogged about the changes to the DSM-V criteria for eating disorders here and here when they were announced in February. I posted the original draft criteria in my blog the day they were announced, so you can refer to them for the changes. And there were two- two MAJOR changes that has me rather excited. I submitted my blog posts to the APA website per their request for comments, and let's just say that our voices have made a difference.

First major change

The "85%" weight criteria for anorexia has been dropped. It has been replaced with the word "markedly" and the new criteria reads as follows:

Restriction of energy intake relative to requirements leading to a markedly low body weight. Markedly low weight is defined as a weight that is less than minimally normal, or, for children and adolescents, less than that minimally expected for age and height.

Which is good, because a low body weight for one person may be normal for another, and the 85% criteria assumes that there is one "ideal" body weight for all 6.5 billion of us.

Second major change

The Eating Disorder Workgroup has changed the definition of "purging" in bulimia nervosa to include fasting, excessive exercise, and abuse of medications. They eliminated the difference in DSM-IV between purging/non-purging bulimia nervosa and just lumped them all in together. The new explanation of purging for BN reads as follows:

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications, fasting; or excessive exercise.

You can still comment on the altered criteria until April 20.

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?

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

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

No kidding.

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

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

I was so naive.

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

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

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

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

What NEDAW message do you want people to hear?

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

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

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

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

And it was. It really, really was.

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

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

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

I had to agree.

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

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

What's your "amazing act of courage"?

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

Bulimia Nervosa

The changes to the BN diagnosis were twofold:

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


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

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

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

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

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

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

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

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

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

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

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

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


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


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

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

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

Binge Eating Disorder

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

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

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

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

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

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

Purging Disorder

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

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

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

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

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

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

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

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

"A soteria is the positive analogue of a phobia. A phobia is an irrational fear of some object, whereas a soteria is an irrational attraction to some other object. In popular US culture, the most famous soteria is Linus's blanket, but I bet that most of us have our own examples, even if we don't have a label for them."

So writes psychologist Christopher Peterson in his blog The Good Life. I've written before about how many aspects of an eating disorder seem like a phobia, but there are also many aspects of an eating disorder that seem like a soteria--albeit a sick, twisted, messed-up one.

Let me explain a bit. I've often thought of my eating disorder as my metaphorical security blanket. No matter how bad the world got, I could always cuddle up with my blankie and make everything okay. Instead of swaddling myself in fleece, I swaddled myself in starvation, exercise, bones, and three layers of hoodies. In a sense, the AN protected me from having to deal with life because the starvation and obsession blunted the sadness and anxiety I so often felt. As long as I was losing weight, or eating a prescribed food plan, or exercising, then nothing else mattered. This happened biochemically, of course, but it also happened in a more nebulous, existential sense. I organized my life around the rules of anorexia.

In a sense, I suppose my OCD rituals and compulsions were also like a soteria. They made the world seem okay. They provided me with a sense, however fragile and fleeting, that I could handle things.

That being said, neither the eating disorder nor the OCD were really a soteria because they weren't a positive analogue to anything. I've never really had lucky socks or a very special token. Outside of the brain disease induced superstitions, I am much more on the dully rational side. And yet I crave the comfort and security of something, of...well, I don't know what. I have a few possessions with an unusual level of attachment (my crochet hooks, my journal, several stuffed animals) that I suppose form sort of what a soteria is. But I can't think of anything concrete, nothing that would counteract the hold of the eating disorder.

I don't know- maybe I don't need something specifically concrete. I would almost prefer something to do, a drive or passion that would overpower the continuing allure of ED thoughts and behaviors, rather than an inanimate object. I'd like to have something, although I'm not sure deliberately looking for a so-called "security blanket" will be the same as just becoming attached to some tatty blanket.

Do you have a soteria? How did you find it?

Although a paper from the research journal Nature was typically covered as yet another reason why fat people are fat, it actually has quite a bit of application to eating disorders. The paper, titled "Regulation of adaptive behaviour during fasting by hypothalamic Foxa2," looked at the relationship between hormones released during short periods of fasting and activity levels in mice.

I'll let a press release from Science Daily do some of the explaining for me:

The key switch player in this is a transcription factor called Foxa2. Transcription factors are proteins that make sure other genes are activated and converted into proteins. Foxa2 is found in the liver, where it influences fatburning, but also in two important neuron populations in the hypothalamus -- the region of the brain that controls the daily rhythm, sleep, intake of food and sexual behavior. The control element for Foxa2 activity is insulin, in both the liver and the hypothalamus.

If a person or animal ingests food, the beta cells in the pancreas release insulin, which blocks Foxa2. When fasting, there is a lack of insulin and Foxa2 is active. In the brain, the scientists have discovered, Foxa2 assists the formation of two proteins: MCH and orexin. These two brain messenger substances trigger different behavior patterns: the intake of food and spontaneous movement. If mammals are hungry, they are more alert and physically active. In short, they hunt and look for food. "If you watch a cat or a dog before feeding it, you can see this very clearly," says [lead researcher Markus] Stoffel.

The researchers discovered a disorder in obese mice: in these animals, Foxa2 is permanently active, regardless of whether the animals are fasting or full. This explains a well-known but until now unaccountable phenomenon: the lack of movement in obese people and animals.

To prove this, the researchers used a genetic trick to breed mice, in the brains of which Foxa2 is always active, regardless of whether they have just eaten or are fasting. These mice produce more MCH and orexin and move five times more than normal animals, in which insulin deactivates Foxa2 after eating or which are obese. The genetically modified mice lose fatty tissue and form larger muscles. Their sugar and fat metabolism works flat out and their blood values are considerably improved.

To simplify even further: hungry mice were more active.

Starving people with eating disorders tend to be more active as well. Excessive exercise is very common in people with eating disorders, and is associated with higher levels of anxiety and somatization (that is, physical ailments brought about by psychological stress). Although most people with EDs cite exercise as a way to lose weight or otherwise self-regulate, it may be driven by other biological factors as well.

So why would biology be prodding an organism to get moving when common sense would indicate that they should be resting and conserving every last calorie? One explanation is that a more active animal will move further afield to seek out food. Sitting around won't get you fed; seeking out food just might. Short-term, this is a costly strategy, as there is no guarantee there will be food anywhere else, either. But long-term, you'll definitely starve if you stay in your den where there's no food, so it makes sense.

Of course, for people with eating disorders, the problem isn't the lack of food as much as it is an inability to eat the food that's already there. The body, however, doesn't really care why you're starving. It just knows you are and prods you to go get soemthing to eat, dammit!

There are models of what is termed "activity-based anorexia" in rats, where an animal on a restricted feeding schedule ultimately runs itself to death on an exercise wheel (Epling, Pierce, and Stefan, 1983). Researchers have looked at the role of leptin (Hillebrand et al, 2005) and a-Melanocyte-Stimulating Hormone (Hillebrand et al, 2005b) in activity-based anorexia, with some very interesting and promising results. This latest research only adds to the hormones that may help regulate energy balance in people.

Several weeks ago, there was a massive to-do over a horrifically Photoshopped image of a Ralph Lauren model. Boing Boing said it best: "Dude, her head is bigger than her pelvis!" And in the image, indeed it was. Ralph Lauren later fired the model, Filippa Hamilton, for being too fat, even though she's a size 4. Last week, documentary filmmaker Darryl Roberts (he directed the movie "America the Beautiful") was supposed to have appeared on Larry King Live until the people at Ralph Lauren allegedly had the segment pulled. Now, the America the Beautiful Action Group has created a Facebook page encouraging people to boycott Ralph Lauren.

I have not joined this Facebook group for a variety of reasons, one being the fact that I never bought any of his stuff anyway, so my boycott of the company would have precisely zero effect on their bottom line. The other major reason is that I really, really, truly dislike how negative ads like Ralph Lauren's are conflated with causing eating disorders.

In an open letter to Ralph Lauren, Roberts writes that:

I’ve had the pleasure of meeting tens of thousands of young girls while promoting my documentary “America the Beautiful.” To look in the eyes of over 100,000 college women and hear their pain (body image, self-esteem) has been an experience that I will never forget. I’ve also heard from over 80,000 parents that are in pain because they have to hear from their sons and daughters in pain. It does truly become a generational cycle.

I’m sure that you’re fully aware that a lot of the American population feels that the unhealthy ads in magazines are damaging to women. The damage comes in various forms; body image problems, low self-esteem and for some of the women, they get a full blown eating disorder like your niece Jenny.

{snip}

Believe it or not, [adults and parents] get hurt as much as the young girls that read the magazines and look at the ads. “How? You wonder.” When a young girl reads these ridiculous fashion magazines and gets triggered into a full blown eating disorder, who do you think gets left holding the bag for the $30,000 a month treatment? I’ve met parents that have had their entire savings wiped out and some have taken out second mortgages on their homes to pay for the treatment of their young daughters.

Although Roberts says that he was told by an ED expert that 50-80% of the risk for developing an eating disorder is genetic, the message here is clear.

I'm all in favor of supporting a boycott for Ralph Lauren because he's engaging in false advertising (which is what I think the dramatically altered images really are), for being denigrating towards women, or for just being a douchebag. All of these are quite possibly true.

All of these have NOTHING to do with eating disorders.

Yes, our thin-is-in culture plays a role in triggering eating disorders, but the holy-is-in culture played a role in triggering eating disorders during the Middle Ages. I'm not saying that we should support or participate in this culture (it's damaging even if you exclude any triggered eating disorders), but we can also oppose it for reasons that have nothing to do with EDs.

Writes Sue Sierralupe of the Oregon Natural Health Examiner:

The National Organization for Women (NOW) is one of the many organization demanding a change in advertising policies that encourage eating disorders. NOW has prioritized encouraging women's self esteem with Body awareness education, "Love your Body Day" and a posting of ads offensive to women and ads that are supportive of women. NOW has asked Ralph Lauren to apologize encouraging unrealistic body images that lead to eating disorders.

...Most cases of anorexia and bulimia are symptoms of unhealthy self esteem. According to the Women's Center for Healthy Living (WCHL), "Anorexia and bulimia are characterized in part by a refusal to eat and repeated attempts at dieting. Even if individuals suffering from anorexia or bulimia are a normal weight, their body images are distorted, causing them to continually attempt weight loss. The thought process of those suffering from anorexia or bulimia is that if they only weighed a certain number, life would be "good" and they would feel good about themselves. The truth is that weight cannot and does not determine your self-esteem or self-worth."

Which is pretty much bass-ackwards. I don't oppose NOW for trying to promote women's health by ads that aren't sexist and offensive. I rather think that's a good idea. But EDs aren't just a feminist "up yours" to the patriarchy done in a nice feminine way. They're an illness.

Many people with EDs have a history of low self-esteem because they also suffered from perfectionism, and nothing saps your self-esteem like the feeling that you are never good "enough." Yet the one thing that absolutely wrecked my self-esteem was my eating disorder. The truly pitiful self-esteem happened after; it wasn't great before, but it wasn't literally and metaphorically in the toilet, either. EDs aren't about the vapid pursuit of an ever-decreasing weight. They're about scrambled neurotransmitters, about how ED symptoms can help mediate feelings of anxiety and depression, they're about genetics, and a vicious cycle that doesn't seem to stop. Furthermore, the symptoms of body dysmorophia and "feeling fat" are a relatively recent phenomenon- they weren't consistently present before the 1800s, and didn't comprise a majority of AN cases until into the 1900s.

Ultimately, Sarah Ravin said it best: this focus on EDs as just really extreme body image dissatisfaction "trivializes the anguish that eating disordered people experience."