I don't know if you've seen the headlines (the story has been making the rounds in the psychology circles for the past day or two), but a study just came out that looked at the relationship between body dysmorphic disorder and nose jobs. The study found that one-third of people who wanted a nose job for cosmetic reasons had moderate to severe symptoms of BDD. Of those who wanted a nose job for medical reasons (to improve breathing, etc), 2% had been diagnosed with BDD.

Except that's not how the study was reported. Instead, headlines like "Nose job patients often mentally ill, study says." An excerpt from this piece below:

Of patients who were seeking the procedure to correct a breathing problem, only about 2 percent showed symptoms of BDD. But of those who wanted a nose job for cosmetic reasons, 43 percent showed symtoms of the disorder.


BDD was especially common among people with a history of mental illness, as well as those who had already had a nose job and were seeking “revision” surgery.

The problem, as John Grohol pointed out on the World of Psychology blog, is that "symptoms of BDD" aren't the same as being diagnosed with BDD. It's a subtle difference in words, yes. But it's a major difference in what we're actually talking about.

I had symptoms of the flu several winters ago. High fever, muscle aches, chills, feeling utterly crap, all with a sudden onset. Classic flu symptoms. Except a flu test revealed that whatever I had wasn't the flu. It looked a lot like the flu, it had the same symptoms as the flu, but it wasn't caused by the influenza virus.

Someone can have symptoms of depression (low mood, feeling hopeless), but not actually have clinical depression. Same with BDD. Same with EDs, too. The scales and questionnaires used in research aren't diagnostic tools. They can give you an idea whether you should see an actual living, breathing professional for evaluation and a potential diagnosis, but they don't say whether you actually have the condition.

It's not the public's job to know this. I'm not saying scientists shouldn't use these measures simply because they are so frequently misinterpreted by laypeople and journalists alike. But I am saying that journalists and editors need to know the difference. It's responsible reporting.

It happens with eating disorder stories all the time. Most commonly, it happens when people conflate disordered eating with eating disorders, or the scores on a survey with an actual diagnosis. The problem is that most people don't know there's a difference between these two things, or that the difference really matters.

Of course we would expect that people seeking nose jobs have higher concern and focus on their appearance. They are, after all, dropping thousands of dollars in an attempt to, you know, look better. But focus on your appearance isn't the same as BDD, and it's offensive to those who are suffering to make the two things equivocal. It's like saying someone who is obsessed with their weight has an eating disorder. They're not the same. At all.

We need to start distinguishing between these two things so that we stop trivializing deadly mental illnesses as little more than cultural fads.

It's pretty much impossible to have missed the devastating earthquake, tsunami, and now nuclear meltdown in Japan.  Massive tragedies like this always throw me, because I think of how petty my concerns are in comparisons.

It's like realizing there are people who don't have food and housing makes me feel pretty shallow for fretting how many fat grams might be in my microwave popcorn.

Despite knowing the pettiness and shallowness, I still fret and these things still worry me.

I'm not trying to compare--because you really can't compare--and I'm not trying to make natural disasters all about ME ME ME as I've been accused in the past.  But it was helpful to hear the mom of a girl recovering from anorexia refer to the illness as her own personal tsunami.

Both are destructive.  Both require a lot of people to help clean up the mess, outside assistance, and things don't just return to normal once the massive clean-up crews return home.

This helped me to put things into perspective.  Not that global events aren't horrific, but so is an eating disorder.  It's a different kind of horror on a much different scale.  But measuring suffering is rather futile, and perhaps even more petty than fussing about fat in popcorn.  I get that a paper cut causes different suffering than losing an arm.  I get it.  I get that losing your house and your family is a hell of a lot worse than wondering if your low fat popcorn is actually the low fat stuff or if the packets might have gotten swapped in the open box and it's actually the stick of butter on each kernel kind.

But if that was the maximum amount of suffering caused by an eating disorder, I would welcome that suffering with open arms.  An eating disorder often seems superficial, as we crane our necks to make sure our asses haven't magically expanded after that extra bite of apple.  But there's a difference from the occasional "Do these jeans make my butt look fat?" and honest-to-goodness watching your thighs expand after eating a meal. Some of us howl and shriek about getting fat and food and calories and it sounds almost identical to the cultural hogwash we hear every day.  Maybe that's how we're translating something that's bizarre and inexplicable.  I don't know.

It's easy to feel guilty for thinking about EDs and recovery when there is so much legitimate suffering going on in the world.  I frequently do.  And yet my neglecting my recovery isn't going to help anyone.  Perhaps my suffering doesn't compare to what people in Japan are going through.  It probably doesn't.  But that doesn't mean that it's not suffering and that my eating disorder is simply excessive vanity.

I read many news stories about eating disorders every week--most of them are okay.  I don't feel that they've turned the world upside down with great knowledge, but they also aren't heinous.

Then there are the heinous stories, about which I need to splutter in verbose dismay because I can't think of anything else to do.

Let's start with the title, shall we?

Addictions & Answers: Behind the insideous 'art' of anorexia

Okay, just to clear up any misconceptions here: ANOREXIA ISN'T ART.  It's not pretty.  It's not insightful.  It doesn't bring value to the world.  Watching your hair fall out in chunks, watching your skin turn yellow and gray, watching your kidneys stop working--this has nothing to do with art.

Being so afraid of eating, or the consequences of eating, isn't art.  It's an illness.  We don't call cancer or diabetes or mesothelioma an "art."  We seem to reserve that concept for eating disorders.  Stop making eating disorders into something they're not.  This so-called "art" kills thousands of people, and precious few people take it seriously.  We need a lot less art concepts and a lot more illness concepts.

I love metaphors, and I have used metaphors a lot to try and explain my own experience of having anorexia.  But there's a difference between using a metaphor to describe something ("It was like being trapped in a burning building") and actually using that something as a metaphor ("The burning building is like our society").  Frankly, I find it insulting and demeaning.  Anorexia-as-art smacks of vanity, of something less than serious, that maybe I huffed a few too many turpentine fumes on my way out the door.  Nuh-uh.

Onto the actual article...An excerpt is below:

BILL: Can't these people just look in the mirror and see something is radically wrong?


DR. DAVE: That's like saying to a meth addict, 'Can't you see you're killing yourself, why don't just stop?'


BILL: Dave, not the same. The meth addict is out-of-his-mind high. The alcoholic who dies in a one car crash or even the gambler who suicides in a deep depression rather than face his creditors—these are things our readers can understand. The closest I can come to understanding anorexia was when someone called it "the art of starvation."


DR. DAVE: Exactly: People like Isabelle Caro and Jeremy Gillitzer are addicted to view starvation as a kind of body image art.


BILL: An art they can totally control.


DR. DAVE: When the 87-pound anorexic loved one is genuinely horrified about how a stick-thin arm is "too fat," and pushes away the plate, barely touched, their families are baffled.


BILL: I can see how easy it is for parents to miss anorexic behavior. Aren't they in the midst of their own post-Christmas diet rituals --Jenny Craig "personal counselors," the new Weight Watchers "Points Plus" programs, and the rest? OK, Doc -- how does a parent or lover intervene to end this addiction?

"Body image art?"  So having anorexia is like getting a tattoo?  My only response to that is WTF, buddy?

The drunk, the meth addict, the gambler are all out of their minds, but someone with anorexia--a diagnosable mental illness--is somehow perfectly sane?  It's not just a bad choice.  The chaotic eating patterns in any eating disorder mean that the brain is painfully, thoroughly affected.  Someone with an eating disorder is exactly like a meth addict or someone as drunk as a skunk.  Their brain isn't working properly.  They need to detox before they can start behaving rationally.  Most starving people aren't completely rational--the men in Keys' Minnesota Starvation Study showed that rather well.

The last thing that really irked me is the comparison of anorexia and dieting.  An eating disorder is not an "extreme" diet or a diet gone overboard.  It's not uncommon for an eating disorder to start as a diet, but that doesn't mean that an eating disorder is a diet.  A suicidal person is often depressed and in a bad mood (trust me on this one).  Suicide isn't just a really rotten mood.  It isn't something you deal with by watching a funny movie and hoping it will go away.

One of the best things about the Internet is that everyone has a voice.  One of the most frustrating things about the Internet is that everyone has a voice.  Some people--especially these two--shouldn't have microphones.  It's one thing to peddle your whackjob theories on your own personal blog, but to have an official "stamp of approval" from a news organization is ridiculous.

Model and actress Isabelle Caro, most famous for posing her emaciated body in a 2008 anti-anorexia billboard, died at age 28.

Her goal, says the Los Angeles Times obituary, was to show others the dangers and horrors of anorexia in order to prevent the illness.  A noble and honorable goal, to be sure--but Caro knew and lived these dangers and horrors of anorexia, day in and day out.  Still she could not shake her illness and instead died at age 28.

The billboard that flung Caro into the limelight was produced by fashion company Nolita, in an effort to raise awareness about anorexia in the fashion industry.  Aside from the fact that I'm not convinced of the relationship between anorexia and fashion, Nolita was happy to use Caro's wasted body in their ads.  They were happy to use the shock value and run with it.  Yes, the company likely meant well by it, but what was that phrase about the road to hell being paved with good intentions?

After the April 2008 billboard, Caro went on to be a guest judge on "Top Model France," to write a book and song lyrics, to appear in television and film.  All while deathly ill with anorexia.

When I heard of Caro's untimely death, all I could think was: these people were using this poor girl.  They knew she was sick.  It was obvious just by looking at her.  They knew she was dying from a lethal illness and yet the chose to look the other way.  Maybe they figured that as long as Caro thought she was fine, then she had to be fine.  She was "trying" to get better, but your heart, your liver, your immune system don't much give a damn about trying.

It was like what I used to tell people: I'm working on it.  Which is all well and good, but Caro's and my lack of progress should have made it damn clear to anyone not blind that no progress was actually being made.

Yeah, I'm angry.  Media outlets and corporations were all too happy to let Caro continue on her merry way and not actually address her illness.  I'm guessing some of them told her she should gain weight and eat some more.  Gee, you don't say.  Caro had probably never heard that advice before, right?  If they cared, they should have refused to cast her until she was healthy.  It's hard enough to give up an eating disorder even when it's robbing you of everything in your life.  But when you can have the life you want and the eating disorder? 

The immediate cause of her death wasn't disclosed.  But the media industry--the very ones Caro turned to in her efforts to warn others of the dangers of anorexia--did quite a bit to contribute to her death.  She very well might have died if she didn't become famous.  Yet the people who knew and worked with her had an opportunity to close down any path but wellness and recovery.  And they didn't.

That's what makes me the most angry and the most sad.  That so many people are willing to ignore such a blatant disorder and look the other way.

As much as I love keeping up to date on ED news and research, I sometimes cringe when I click on a link.  Is the author of this news story going to screw it up?  Will they have done their homework?  Much of the time, the stories are a mixed bag--some bits are okay, some could use a bit of tweaking.

Every once in a while, though, someone knocks it out of the park.  With these two stories, though, the authors didn't do so in a good way.  It was awful.  I don't know whether I blame the journalist more, or I blame the people they interviewed.  Or both.

So for the first one:

Is Victoria's Secret Peddling Eating Disorder Porn?

No, Victoria's Secret is peddling overpriced unmentionables.  They're also peddling sex and clothes that make your partner want to do you.  They're peddling an image.  They're peddling an image of a sexualized, idealized women with huge boobs and a tiny waist.

It's very common for people with eating disorders to compare themselves to these idealized images and find themselves wanting.  It's also very common to try and lose a few pounds or get breast implants.  All of which are a waste of time and money and form a tremendous drain on society.  But really?

Eating disorders existed long before women with gigantic breasts and push-up bras paraded around on national television. In the Middle Ages, women with eating disorders compared themselves to holy women and other saints.  Those were the idealized images of what a woman could be, if she tried hard enough.  Part of that trying involved fasting for religious purposes. 

Today, some people with eating disorders fast for cosmetic purposes, or to be better at a sport or it just sort of happens.  It could very well be that women in the Middle Ages had a variety of reasons that motivated their behaviors.  They probably did.  The world may very well be a better place if Victoria's Secret disappeared. It would definitely be a better place if we stopped promoting only one body type as beautiful or sexy.  But whether there would be fewer eating disorders?  I'm not entirely convinced. 

These images, and our society's obsession with food and fat, are the cultural backdrop against which eating disorders occur.  We use and co-opt this language to help explain what we're going through.  Although exactly what motivates an eating disorder is far from irrelevant, motivation doesn't always explain causation.

Which brings me to the second article.

Butler Hospital Physician Too Familiar With Eating Disorders

Based on this doctor's quotes, however, I might advise a little more familiarity before saying such things as this:

Qualls said the disease usually arises from a person’s unhappiness with their appearance.

The media play a role in the equation, he said, providing a model of the body that may not be realistic or healthful for people to strive to imitate.

...Diseases such as compulsive purging or not eating tend to occur during transitions in life, he said. Among them: girls going from eighth grade to high school, “which is a triggering event because all of the sudden boys become more important,” he said. “The next change is when they go into college. Once they experience [a disorder], they are at risk of this recurring at any point for the rest of their lives.”

*headdesk*

In case this isn't obvious by now: my eating disorder had nothing--nothing--to do with wanting to look good or attract men.  Nothing.  I thought that eating better, exercising more, and yes, maybe losing 5 pounds would help me feel less depressed.  After a while, I knew I looked atrocious.  I thought nothing about sex and dating.  I knew that the ED was destroying my health and appearance, and yet I couldn't stop.

The concept of "re-education" sounds very Soviet, and maybe it is, but I kind of want to have an intensive training program for these journalists and especially these doctors before they are allowed to even see another ED patient.

Not as a writer, though. I was interviewed by the fantastic Anna North on the subject of eating disorders, mental illness, and dating. I think the article turned out really good. My friends Tiptoe, Meggy Wang, and Sarah Ravin are also featured.

Check it out here:

The Delicate Balance of Dating and Mental Illness

A few minutes ago, I got this update from my friend Harriet Brown, author of the upcoming book Brave Girl Eating.

"The Good Morning America appearance was canceled after I refused to allow photos of my daughter at her sickest appear onscreen. Makes me ashamed to be a journalist."

Because there's no other way to talk about eating disorders and treatment and recovery than showing pictures of emaciated children...right?

Save the voyeurism for bad reality TV shows. We don't need it to show how devastating an eating disorder can be.

It's GMA's loss, really. The appearance would have been a great opportunity to educate people and dispel myths about eating disorders. And now, because of a producer's stupidity, that opportunity is lost.

Will people ever learn?

A recent editorial titled "A Western illness best forgotten" is so off-base and so incorrect, that it can't even be classified as wrong.

And because there's no real way to paraphrase such insanity, I'll let the author speak for himself:

Of course, the desire to have the state influence how satisfied or unsatisfied we are with our bodies is totalitarian, but I had assumed it was essentially harmless - Melbourne University churns out a lot of arts graduates who have studied feminist and cultural studies and these people need to be employed somewhere.

The chances of the Government succeeding in influencing how attractive we find fat or skinny people to be are of course almost nil, but if it keeps a few Labor and Greens voters happily employed, then that's fine by me.

True, some people have questioned whether it is wise for the most overweight societies in human history to be spending money making its fatties feel better about themselves.

They have wondered whether the Government may not be better off spending our money telling us that if we have a negative body image it is because we are lardarses who need to eat less and exercise more.

...In the West, anorexia is most likely to strike urban girls from middle-class families who are often high achievers. The few anorexics in Hong Kong tended to come from poor rural villages where the influence of Western culture, with its adoration of the young and skinny, was weak.

The strangest thing Dr Lee found though, was that the anorexics he saw had none of the self-delusion about their body size that Western anorexics do.

Asked to draw themselves, these anorexics correctly pictured themselves as dangerously thin, whereas Western anorexics will usually draw themselves as overweight.

The Hong Kong anorexics attributed their failure to eat to physical factors such a bloated stomach or blockages in their digestive tracts rather than a desire to be thin.

When he investigated the history of the disease, Dr Lee found that the earliest Western descriptions of the disease from the 1820s more closely matched the patients he was seeing than the textbook definition of anorexia.

In the early 19th century the disease was so rare that it wasn't until 1873 that medicine could even agree on a name for it. In that year a French doctor delivered a paper that sparked widespread interest and understanding of the existence of the disease.

The really interesting thing is what happened next. Though in the 1850s anorexia was a rare disease, by the end of the century it was commonplace. The growth was so marked that it could not be explained away as the result of doctors finally picking up on a disease that had always existed, but of which they had been previously unaware.

In other words, the widespread knowledge of the existence of the disease was responsible for spreading it.

Watters then catalogues the way in which the Western form of anorexia developed in Hong Kong after the media there highlighted a schoolgirl who died of the disease. Within a few years Hong Kong went from having almost no anorexics to being full of them.

Apparently James Campbell missed the first lesson in Epidemiology 101: correlation doesn't equal causation. He doesn't account for the fact that increased awareness of an illness can lead to increased diagnosis, not increased incidence. Maybe I'm off-base, but it seems that increasing diagnosis and treatment of an illness was a good thing.

Furthermore, most people with anorexia don't deliberately try to end up that way. They either eat less or cut out sweets or try to lose a few pounds and then they find themselves stuck in an anorexic hell. Anorexia is ego-syntonic; that means that sufferers don't see the illness as a problem, and that the outcome of the illness (weight loss) is a good thing. As the Western cultural ideals of weight loss and thinness have spread, it doesn't seem unusual that someone with an ego-syntonic illness would latch onto these as a justification for thoughts and behaviors that seem pretty bizarre. With more people dieting, you would naturally expect to have more eating disorders triggered.

I honestly believe that the body dysmorphia is a culturally mediated aspect of anorexia. Culturally-mediated doesn't mean that there's no biological basis, just that you only see these symptoms in certain cultures. Biology helps explain why not everyone in this culture has the symptoms/illness, but the body dysmorphia in anorexia does seem to be pretty consistent with modern, Western cultures (it is much less prevalent in young children with anorexia). But that in and of itself isn't anorexia. It's just one aspect of the illness.

Anorexia is NOT a Western illness. It exists in China, Ghana, and Curacao, at rates that are roughly comparable to the US and Western Europe. Say it with me in a sing-song voice now: someone didn't do his research...

Then there's the issue that if we pay attention to eating disorders, they will go away. To me, this smacks of the larger write-off that many people with eating disorders get, which is: "They're just doing this for attention! If you ignore it, they'll stop!" One must wonder, then, why people with EDs go to such extreme lengths to hide their symptoms if what they really want is attention.

BP ignored the problems in their oil well, and we all know how smashingly that one turned out. As a culture, we've tried to put blinders on to issues like teen pregnancy, homosexuality, and environmental decay, hoping that they will just "go away" and that one day, we will all laugh at how teens used to get pregnant, people were attracted to someone of the same sex, and we honestly thought the world was going to hell. If it worked, it would be convenient. But it doesn't work.

Rates of some cancers have increased over the years, and we don't blame the War on Cancer. When heart disease rates go up, we don't boycott the American Heart Association for trying to help. Anorexia isn't just biology--culture is important. But ignoring a problem to make it go away? It's a short-term solution to a long term problem.

Howdy there. I'm fighting off a nasty cold/cough combo at the moment, and so my brain is rather congested and I want to get to bed early. I even skipped my bike ride today (though thanks, self, for reminding me of that!).

I will be back tomorrow, hopefully with sinuses that are less overflowing and a throat that feels less like I'm swallowing razors. Until then, I ask you to read this great article:


Finding a Healthy Medium: Eating disorders don't discriminate based on size

May this be the start of a new trend on educated, compassionate reporting on eating disorders.

Feel free to share your favorite article/story on eating disorders in the comments!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The New York Times had a wonderful article by Abby Ellin, author of "Teenage Waistland: A Former Fat Kid Weighs In on Living Large, Losing Weight and How Parents Can (and Can’t) Help," called Narrowing an Eating Disorder, which looked at the troublesome diagnosis of EDNOS and what should and could change for the DSM-V.

Writes Ellin:

To maintain some semblance of control, I divided my eating into Food Days and Nonfood Days: that is, days when I consumed vast amounts, and days when I policed my caloric intake with military precision. The routine kept my weight in check, more or less. Never mind that it was insane.

No one at my college health center knew what to do with me. Clearly, I wasn’t anorexic; I was slightly round, in fact. I didn’t purge, so bulimia was out. To my distress, the counselors told me there was nothing they could do for me and sent me on my way.

Today, I would probably qualify for a diagnosis of “eating disorder not otherwise specified,” usually known by its acronym, Ednos.

The majority of eating disorder diagnoses are, in fact, EDNOS. I'm not saying that the EDNOS category isn't useful (it can capture emerging trends in ED behaviors that might not fit into any other specified categories rather than just ignoring them), but if "not otherwise specified" is the most common diagnosis, it's a sign that we don't do a good job of defining what eating disorders exist out there. In a major study on the severity of EDNOS (Fairburn et al 2007), researchers found that:

These cases closely resembled the cases of bulimia nervosa in the nature, duration and severity of their psychopathology. Few could be reclassified as cases of anorexia nervosa or bulimia nervosa. The findings indicate that eating disorder NOS is common, severe and persistent. Most cases are "mixed" in character and not subthreshold forms of anorexia nervosa or bulimia nervosa. It is proposed that in DSM-V the clinical state (or states) currently embraced by the diagnosis eating disorder NOS be reclassified as one or more specific forms of eating disorder.

Fairburn in particular is known for his thinking on the "transdiagnostic model of eating disorders," which he explores in depth in a paper titled "Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment." Fairburn believes that the varying clinical symptoms and psychopathology of eating disorders are maintained by similar processes (clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties), that distinguishing between different ED diagnoses is the psychiatric equivalent of hair-splitting. Simply speaking, eating disorders have far more similarities than they do differences. Whether or not you entirely agree with Fairburn (I'm not entirely convinced myself), he does have some very good points.

With the upcoming DSM-V revision, clinicians and researchers have been looking at potential changes to the ED diagnostic criteria. A recent full-text article in the International Journal of Eating Disorders titled "Broad categories for the diagnosis of eating disorders" received great coverage over at Psychotherapy Brown Bag, and rather than reinvent the wheel, I will leave you to their wonderful shake-down of the evidence and its implications.

Dr. Tim Walsh at Columbia University had a great quote on the issues with the "EDNOS" diagnosis as it is currently used:

“The consensus is that Ednos is ‘too big,’ meaning it is being used more frequently than is desirable, as that label does not convey much specific information,” said Dr. B. Timothy Walsh, a professor of psychiatry at Columbia who is chairman of the eating disorders work group for the new manual.

Then there are the intricacies of the psychology so unique to eating disorders that also presents problems with the EDNOS diagnosis:

“A lot of patients feel this stigma if they know they’re diagnosed with Ednos: ‘Obviously, I’m not good enough to be anorexic,’ ” said Nicole Hawkins, director of clinical services at Center for Change, an eating disorder treatment center in Orem, Utah. “I’ve had many patients feel that they need to lose more weight so they lose their period so they can change the diagnosis. Patients really feel they have to get ‘better’ at their eating disorder to deserve treatment.”

Perhaps the most erudite comment in the whole article that completely exemplifies what is wrong with the DSM in general and EDNOS in particular is from Dr. Craig Johnson of the Laureate Eating Disorders Clinic.

“What Ednos really demonstrates,” said Dr. Johnson, at Laureate in Tulsa, “is that we don’t have empirically derived diagnoses in psychiatry."

I don't generally read the comments to articles like this, but there was one comment from the Well blog post on this article that completely exemplifies our culture's messed-up relationship to eating disorders:

Could someone please explain which alternating Food/Non days is a disorder. If it helps one manage food, sounds just fine with me. It ain’t gonna kill the patient!!!

Except that it very well might.

For more reading on the DSM-V and eating disorders, check out these full-text articles from the International Journal of Eating Disorders.

I think I've blogged on this before, but the recent uptick in "-orexia" terms in the news have me more than a little annoyed.

"Brideorexia" is defined by the Urban Dictionary as "When a bride goes overboard trying to get skinny for her wedding day." The dictionary uses the term in a sentence as: Damn, How did she get so f*cking skinny?!?! She came down with a case of brideorexia!

I get that the Urban Dictionary isn't the Oxford English Dictionary, but would it be too much to ask for a hint of accuracy and classiness? A woman isn't absolved of an eating disorder when a ring is slipped on her finger and she does shopping for the Pretty White Dress. Nor does the Pretty White Dress provide immunity from developing an eating disorder. It might be more expensive than almost any item of clothing she has bought before, but it's still just a dress.

"Drunkorexia" means that a person restricts their food all day to "save up" for the calories consumed during a night of alcohol consumption. Now, the comorbidity of eating disorders and alcoholism is well known and sadly rather common. But drunkorexia isn't the lone purview of sorority girls and frat boys at a kegger. Alcoholism and eating disorders can and do exist side by side. But this isn't particularly novel, and certainly not a "new" disorder. The struggle of those who deal with both EDs and substance abuse shouldn't be minimized by some cutsey name.

"Stressorexia" typically occurs when working moms get too stressed or busy to eat, and begin the cycle of weight loss and disordered eating. Stress is a big trigger for eating disorders, and I certainly see how stress and loss of appetite can lead to the beginnings of an eating disorder. But unlike several publications have observed, stressorexia isn't a "new" eating disorder. It might be a new cadre of excuses why you can't eat or don't have time to eat or why you've lost weight. It might be a new background against which eating disorders are expressed. But seriously? The stress/eating disorders link is hardly a new disorder, nor is it separate from any other eating disorder.

I'm not against publicizing a surge in eating disorders amongst working mothers, and certainly those women who will strive the hardest to be the "perfect" mom and employee will be the most likely to fall victim to an eating disorder. And there's a big difference between using stress as a reason to skip lunch and lose a few, and an eating disorder that may result.

We also have pregorexia, where a pregnant woman is afraid to gain the necessary weight for her and her unborn baby. It's described as "the pregnant woman's eating disorder," as if it's something to covet. A pregnant woman with an eating disorder is precisely that: a pregnant woman with an eating disorder. And women with eating disorders are not refusing to gain pregnancy weight out of desire to be like some thin celebrity; they're afraid to gain weight because of a life-threatening eating disorder. Someone who wants to stay thin during pregnancy might have issues, but it's different than an eating disorder.

There's manorexia, which is a man who is anorexic. Other than the presence of a Y chromosome, it's still anorexia. A male's experience of an eating disorder would be different than a female's, but that doesn't mean it's a different disorder. A 12-year-old girl's experience of anorexia is different than mine, someone who is nearly 30, but no one would diagnose her with "girlorexia."

Would they?

Virtually all eating disorders begin with a diet. And chronic or pathological dieting can easily progress into an eating disorder. I would never really dispute this, as the research supporting it is quite established and quite solid. A period of inadequate nutrition tends to be the last straw that pushes someone from being "at risk of developing an eating disorder" into "actually having an eating disorder."

This does not mean that an ED is just a really big diet.

Which is why this article has me more than a little tweaked: Too much dieting could be anorexia

Anorexia and strict dieting can look the same from the outside, and can even start off the same: food restriction, eating "healthy," reading food labels, exercising more, becoming obsessed with food and cooking. Some of these are sympoms of malnutrition, some of them are just common links. But that's where the similarities end.

Dieting is a choice.
Anorexia is a brain disease.

Dieting is choosing to eat less.
Anorexia is the inability to eat enough due to a fear of food.

Big difference.

So yes, dieting can look like anorexia, and people with anorexia often claim they are dieting or eating healthy. People with anorexia can often think that they are just dieting or eating healthy. A diet can turn into anorexia. But dieting has an element of voluntary choice that's simply not there with anorexia and other eating disorders. No, it's not that simple to just stop dieting, but there is some amount of control over your food-related behaviors. With eating disorders, that virtually disappears.

Not that remedying this misunderstanding will fix everything that's wrong in the ED world, but this seems as good a place as any to start. Once we stop looking at EDs as a bunch of wacky diets undertaken by vain little girls, and start accepting them as a brain disease that needs urgent, immediate treatment, the better off we'll all be.

The article itself didn't arouse too much ire in me, but the headline sure did! So I'm asking you yet again: journalists, please try harder.

Eating disorders (and related issues) have appeared numerous times in the New York Times this week. Besides informing everyone of what I read while I enjoy my first cup or two of coffee, I am glad to see coverage of EDs beyond what celebrity is now doing Master Cleanse. The stories covered thorny issues such as midlife eating disorders, EDs in men, and when your parent has an eating disorder. That these issues would get such wide exposure in such a well-regarded publication is fantastic.

So that's the good news. The actual substance of some of the coverage (besides the major article on midlife EDs), however, was a little lacking. To be fair, I should be specific, which leaves me a little squeamish but deep breath, here it goes. I was really disappointed in the "Consults" blog extras relating to the midlife EDs story. Not that Dr. Zerbe isn't qualified to be a correspondent for such an article, but I felt that she focused almost exclusively on psychotherapy and environmental factors related to EDs to the detriment of what the latest science indicates.

In her responses in the blog post titled "Seeking Help for Anorexia, Bulimia, and Binge Eating Disorder," Zerbe addressed issues of biology and bulimia (it's roughly in the middle of the page). Although she definitely said that EDs have a genetic influence, she was quick to tell the person to look at issues of culture and try to figure out the reasons "behind" their eating disorder. To help with that, she recommends sufferers read stories written by ED survivors.

These stories of recovery in the face of life’s inevitable traumas and struggles paint a broader picture of what it takes to get better and why someone may have arrived at struggle with body image in the first place.

In the most recent blog about "When a Parent Has an Eating Disorder," Zerbe also failed to mention the well-known (in the ED world, anyway) fact that EDs run in families, due not just to shared environment but due in no small part to genetics. Could the man writing in have been helped also by learning that the traits with which he and his parents have struggled are genetic in basis and aren't simply due to bad parenting? Sure, these traits can cause parents to do things that are less-than-helpful, and a good therapist can help deal with the aftereffects. The biological basis hasn't absolved me of all anorexia-related guilt, as I still carry plenty, but it definitely took a weight off my shoulders.

What is wrong with saying that some people got smacked with the shit stick when it comes to EDs and body image? Yes, our culture has a multitude of issues about weight and shape and appearance, but that's not exactly an eating disorder. In fact, it's astounding to think that more people don't have eating disorders when you look at our messed up world.

Am I being nitpicky? Perhaps. But this is also one of those things that never fails to get my panties in a knot. When it comes to eating disorders, I was always told psychotherapy, learn to love your body, figure out what's causing your eating disorder, and my, isn't the idea of size zero pretty effed up? Well, yes, it is, but all those years of looking at those issues did me almost no good. Why are people so hesitant to say "It's the biology, stupid!"* Saying something is based in biology is a far cry from turning us all into DNA code-reading automatons. But it's the way forward in determining better treatments for EDs.

*This is a quote adapted from Dr. Tomas Silber, who I interviewed for my Washington Post article. His direct quote was "It's the nutrition, stupid!" It didn't make it into the actual article, but it's a great quote. Those of you who have heard him speak will know of the hypnotic accent in which he expressed it, too.

I have much sympathy out there with journalists and reporters, seeing as I am one of them from time to time. Writing on deadline is difficult. Eating disorders are subjects that are fraught with meaning, are not well understood by most people, and are amazingly easy to inadvertently sensationalize. And it is the so-called "meaning" of eating disorders that has me the most tweaked about two stories that I read about today.

One, from CBS titled "Tweens Starving for Perfection," had me annoyed from the title. An eating disorder is NOT ABOUT starving for perfection! It passes along the subtle but absolutely incorrect idea that starving or losing weight will make you perfect--or at least "better." Second of all, I understand very well that an eating disorder can take on meaning in the context of our individual lives. My own experiences have meaning, and so do everyone's, eating disordered or not. But my symptoms (starving, purging, over-exercising) weren't meaningful. They were the result of an illness, not a conscious desire to look better.

I see exactly where people get confused. Hell, I was confused and mired in a cesspool of potential meaning and uninterpreted histories for several years. It was only when I was told, over and over like Robin Williams did to Matt Damon in "Good Will Hunting," that anorexia was a brain disease and these actions were symptoms of an illness. They weren't me trying to express myself on a subconscious level- the only thing they meant was that I had an eating disorder.

Only, humans like to explain things. Think of how many creation stories out there address the question of "Who are we and where did we come from?" Eating disorders are baffling illnesses, both to loved ones and to the sufferer. When I was freaked out by my OCD symptoms in high school, I thought I was being punished for some unknown transgression by the Big Guy in the Sky. It was the only way I could make sense of it. As I went looking for an explanation for my intense fear of food, some of these ideas like "control" and "perfection" made a lot of sense. I freely admit I like to control my world and anyone who has ever met me can attest to my perfectionism. It did kind of make sense.

But my OCD wasn't punishment for a sin, and my anorexic symptoms were largely meaningless. Finding meaning doesn't bring recovery. Finding meaning may be psychically helpful, but I've found it largely useless in getting better. Incorporating your experience into your life story, weaving them into your own personal narrative and giving that some meaning- this is useful. Tremendously so, as I have done it and continue to do it. But that's not the same as saying I was starving for perfection. I was starving because I had anorexia, period.

Many of my complaints about the CBS story can be echoed with respect to this story from ParentsCanada called "Dying to Fit In: Do you know what your tween is not eating?" Schizophrenia is not dying to hear more voices, and depression isn't dying to be sad. Diabetes isn't dying for higher blood sugar, and cancer isn't dying for a larger tumor. An anorexic isn't starving for perfection and they're not dying to fit in. They're just starving and dying. And the sooner we can strip away this false meaning, the better we can get aggressive treatment and nutrition for the people who need it the most.

Raising awareness of eating disorders, especially in age groups where you might not be actively looking for them, is good. But please, try just a little harder. Please. It matters.

(Also see Laura Collins' excellent analysis of the CBS story here)

Today, I had the great fortune of reading two great pieces from Australia on eating disorders.

The first is an article titled Anorexia's Lifelong Legacy from the Sydney Morning-Herald, about how eating disorder diagnoses are missed in many boys, simply because pediatricians aren't looking for them, and don't think that males get eating disorders. Because proper, quick diagnosis has a large impact on disease outcome, these kinds of stories are very important. Besides covering this timely and important topic, the article did so in a scientifically accurate way. Some of my favorite quotes:

"When kids are starved, their brains shrink, they're more likely to get depressed and anxious, their thinking slows down and memory falters," Madden says. "This affects their relationships with their friends. The effects can be reversed with re-feeding, but not always."

These serious complications can be prevented if children at risk are picked up early. "If children get the right treatment early, 70 to 80 per cent get well in 12 months and 90 per cent are better in five years. This is much better than in adults where the recovery rate at five years is less than 50 per cent," Madden says.

And

Whether an eating disorder can take hold and thrive seems to rest in the balance of risk and protective factors that a person experiences. In the last few decades, the increasing number of risk factors experienced by children - such as stress, anxiety, dieting, body image worries, and exposure to media images and messages that equate fat loss with happiness - may be creating an unhealthy tipping point.

And

The media comes under fire, not as the cause of eating disorders, but as a potent "enabler" of fat phobia, body discontent and restrictive eating in young people...Kohn agrees that children are being influenced by anti-obesity messages. "Vulnerable children hear them in the wrong way and take them to the extreme. Then a physiological mechanism kicks in, reinforcing the behaviour. Eating less and losing weight dampens down the serotonergic mechanism in our brain that processes emotional responses. This makes the children feel better, calmer, less reactive. Their behaviour improves and they get positive feedback, locking in the dieting behaviour."

I wish more articles on anorexia were like this, chock-full of the latest research and entirely lacking in sensationalism and parent- and sufferer-blaming.

The other good read from Down Under is the book "My Kid is Back: Empowering Parents to Beat Anorexia Nervosa" by June Alexander. The book arrived in the mail on Monday, and I've been steadily chipping away at it ever since. As the title suggests, it is more intended for parents than sufferers, and contains the stories of several families who have helped their children conquer their eating disorder. Filled with wisdom and hope, it will be a great read for people needing encouragement along this long journey of recovery. It officially arrives for sale in the US in September, and you can pre-order your copy from Amazon.

Enjoy your Down Under reads- I know I am! Now, about that duck-billed platypus...

The satire in The Onion always seems to be more truthful than the straightforward newspaper articles. And once again, they nail it, this time with this little gem:

Woman Upset At Herself For Feeling Hungry
MODESTO, CA—Telling friends that she "just ate a huge thing of yogurt four hours ago," local woman Vanessa Stroud chided herself Tuesday for feeling hunger, a natural urge experienced by all living creatures to ensure they consume the sustenance necessary to maintain metabolic processes and other vital biological functions. "God, I have no willpower at all," Stroud said regarding her inability to go without nourishment of any kind until the start of bikini season. "It's just my stupid brain telling me I need to eat when what I really need is another three-day cleanse." Stroud was later seen swatting her own hand as it reached out for a blueberry muffin.

How many of us can relate? It seems obvious that such behaviors are odd and irrational in others, but it's so hard to see it in ourselves.

I read an interview in the New York Times with Susie Orbach, author of Fat is a Feminist Issue and Hunger Strike, and the newly released Bodies. Although I don't agree with her assertion that feminism will 'solve' eating disorders (as EDs are biologically based mental illnesses), I do believe that they are a feminist issue. Why? Eating disorders do affect women which makes them a feminist issue.

And I think many of her points are relevant to today's society: that corporations stand to make a lot of money when women hate their appearance. Also that a pervasive dissatisfaction with your appearance ultimately takes away from our culture. Who knows what things I might have thought if I weren't preoccupied with food and weight.

What Orbach touches on, but doesn't expressly say, is that we are equating what you look like with who you are as a person. Think about the literature on obesity. "Fat" doesn't just mean "more adipose tissue." On a cultural level, "fat" means "lazy," "no willpower," "gluttonous," "stupid," etc.

...but the byline was better.

Check it, kids: the Washington Post actually let me write for them. I convinced them to run a special article for Eating Disorders Awareness Week, on using Maudsley Family-Based Treatment.

Extreme Measures: A Girl's Suffering Drove Her Parents to Explore New Treatment

A special thank you to all those who let me interview them and shared their stories.

As a science writer, a variety of press releases on the latest research--from physics to neuroscience--cross my desk each day. But when I saw a press release for the following article, I knew that media outlets around the world were going to have a field day:

Evidence of gender differences in the ability to inhibit brain activation elicited by food stimulation

More than the study, what interested me was how the subject was going to be twisted by desperate reporters the world over. They did not disappoint.

The study itself was based on PET scans of the brains of 23 "normal-weight" individuals who fasted and

then either focused on a favorite food or used a technique called cognitive inhibition to suppress thoughts of hunger and eating. When the subjects focused on their favorite food, the hunger and desire for food increased at a similar rate in both sexes, as shown in brain scans using positron emission tomography (PET). Although cognitive inhibition decreased hunger in both sexes, the technique significantly lowered desire for food only in men. PET brain scans showed that men using cognitive inhibition techniques showed a decrease in brain activation in the regions involved in emotional regulation, conditioning, and motivation. These regions are known to play a role in processing the conscious awareness of the drive to eat.
(from the original press release)*

The headlines, however, told a very different story. Some of the top ones?

Hunger Control: Women the Weaker Sex? (WebMD)
Why Saying No to Foods May Be Harder for Women (Washington Post)
The secret of successful dieting is in your gender (The Independent, UK)
Women Can’t Say No to Their Favourite Food! (eFlux Media)
Women No Good At Resisting Food Temptations: Study (E Canada Now)
Weak-willed women give in to food cravings (Healthcare Republic)
Why Men Are Better Dieters Than Women (Time)
Revealed: Why women find it so hard to diet (Marie Claire UK)

Appalling doesn't even begin to cover the implicit assumptions in the headlines (Women have out of control appetites that must be curbed! Women are weak! Women have no willpower!), nor do they really reflect the content in the paper. Scientific American had a pretty decent summary (and non-offensive headline!), and even looked at the study's limitations, such as a small number of subjects and that the subjects were not actually given the choice whether or not to eat- they were just asked to convince themselves they weren't hungry. And there are plenty of limitations of brain imaging studies, though they also yield fantastic information.

Blogger Sandy Szwarc of Junkfood Science has written several times on the dangers of science by press release. I don't think press releases are going to go away. Most newspapers don't have a science section and fewer still have any health reporters- the Washington Post doesn't. They borrow from other sections for their stories. And most writers don't have the time or expertise to plow through the thousands of research journals out there. However, they should know better than to parrot a study's grand claims without further investigations (wouldn't happen in any other field).

*The original press release isn't openly available online, but if you're really interested, I have a copy saved on my desktop. And please, for my privacy, if you know how I stumbled across this information, please don't mention it in the comments. I'm a professional science writer- 'nuff said.