Many of you have been asking for a shakedown of my NEDA talk on relapse prevention.  So, without further ado, here are my thoughts.

I presented on relapse prevention (with the help of some LOLcats), basically using the information from my relapse prevention series from earlier this summer.  Yes, this was deliberate--I knew I would be presenting on the topic and thought I would double dip a bit to get some of my work out of the way and have a good blog series.  The presentation itself was a total rush of adrenaline, and I remember only two things:

1) One of my slides had a typo (it read "you" instead of "your")

and

2) One of the animal pics I used didn't elicit the same laughter as the others.

So yes, I remember the details and negative ones at that.  I do think the talk as a whole went exceedingly well, but much of it was a blur.  I spent the morning guzzling coffee to combat sleep deprivation, and then I had to take some lorazepam before the talk started because I was shaking and nauseous from nerves (and potential caffeine overdose).

My co-presenter and former therapist Stephanie rocked it out--it was so wonderful to work with her as a colleague rather than as just a client.  We made a fantastic team fighting ED, and we made a kick-ass team doing our presentation.

After we got done, my mom came up to the both of us and asked, "So did the two of you have fun?"  I raised and eyebrow and said that "fun" definitely wasn't the word I would have used to describe presenting.  It was, however, very rewarding and enjoyable in its own way.  It's not going to be my career, if for no other reason than public speaking would involve way more traveling than I would like!  I'm hoping to present at other eating disorder conferences, and I hope to meet some of you there!

I know, it's cheesy, but I've found the best form of relapse prevention is simply living a fulfilling life outside my eating disorder. This doesn't mean that relapse is impossible, or that slips won't ever happen, because that's not quite true, but what it does mean is this: I have something to lose by giving in to the anorexia. Even last spring when I was relapsing hard-core and was finally aware of it, I didn't care enough to stop. Not eating was the only thing that mattered. If I screwed myself over professionally, so what. I had no real motivation to fight the anorexic thoughts and so I found it so much simpler just to give in.

Part of the reason I was able to hold onto recovery during my year in grad school in Baltimore was that I found my program so remarkably fulfilling. I had found what I wanted to do with my life. I felt reassured that after so much floundering and searching, I had found the perfect profession for me. Not that my time in grad school was ED-free, not by a long shot. I struggled immensely to stay on track, often barely clinging to recovery and the bottom end of my minimum healthy weight. Yet my numerous and rather regular lapses and returns to ED behavior didn't turn into a full-blown relapse, either. I kept my demons in check. I had a fighting chance.

However, as I became disillusioned with my first job out of grad school, the eating disorder crept back in even more. The life I thought I was going to be living turned out to be quite a bit different than I thought it would be, and I began to lose my motivation to fight. Giving into the ED behaviors became the rule rather than the exception, and I slid into utter despair. My life was both still dominated by the eating disorder and anything but fulfilling.

Part of what this last relapse did for me, by being so spectacularly dramatic, awful, and life-shattering, was that it gave me the freedom to start over. I truly had nothing left to lose. My career had already flopped several times--what was one more? I was unable to hold down a regular full-time job (I was living in Michigan and so I knew I wasn't going to find a job, either), I didn't need to pay rent, and I had already screwed up my life so horribly that one more screw up would hardly be the straw that broke the camel's back. With nothing left to lose, I took a chance: I decided to pursue freelance science writing as my full-time career.

What ultimately saved me during my past relapse was my cat. I promised her I would never go away and leave her again, and I was determined to keep that promise. It didn't stop my relapse, but it did keep me alive. Now, when I have ED thoughts or feel tempted to engage in ED behaviors, I know that a relapse would be incompatible with the life I want to live as a writer. I do slip and inadvertently or deliberately restrict or indulge my exercise compulsion or debate about buying laxatives to have on hand "just in case." When I step on the scale at TNT's office, I still hope I have magically lost weight. I body check in the mirror frequently. Writing hasn't made me recovered, but it has helped me keep my eating disorder tightly confined. I want to be a science writer more than I want the comfort of anorexia, of skin and bones, of starvation and compulsion and, ultimately, death.

Recovery and relapse prevention are, as Emily Troscianko writes, not only about stopping starving but also about starting living. It's both the goal and the route to that goal.

So I've gone through my Prelapse Signs, and my red light, yellow light, and green light signs. Although I think it's invaluable to know areas that are likely to trip you up, it's also important to be aware of (to paraphrase Donald Rumsfeld) the things we don't know we don't know are going to sideswipe us.

Case in point: when I was in Europe last month to attend the AED Salzburg meeting and then tool around Austria for a week or two, I got a nasty stomach bug. This meant intense nausea, being unable to eat, and other fun symptoms that I'll leave to your imaginations. As a result, my eating was dramatically diminished for several days and dwindled to apple juice and some pretzels on one day. My mom was, not surprisingly, freaking out until she got what I had and we were both puking.

My mom's concern was that this not eating would make the ED thoughts come roaring back. I vaguely scoffed--the ED thoughts had been no worse than usual during the trip, and I'm doing better than I ever have, recovery-wise--and for much of the time, it was a moot point. I couldn't have eaten anyway. However, as the nausea started to diminish, I was at first very hesitant to start eating more simply because a) I was enjoying the novelty of no nausea and b) I was afraid it would aggrivate my stomach. Then the pushback started to take on a life of its own, and I just didn't want to eat. I started thinking that maybe this would be the perfect opportunity to lose some weight, and...

Yep. I was totally gobsmacked. I was back into full-blown ED thoughts and it seemed there was no "real" trigger. Except that bit about not eating.

Stomach bugs are inevitable, and so (almost certainly) is an inadvertantly missed meal or snack. Here's the thing: before I left treatment, I was warned about all sorts of relapse triggers, such as family problems, reading fashion magazines, hearing people talk about their diets, or other stressors. What no one mentioned was that being unable to eat (whether it was due to a virus, being stuck on a tarmac for 8 hours, whatever) for any period of time could also be a trigger. I never thought it would be such a potent trigger, either. You'll notice most of my relapse prevention plans don't really have much to do with these situations. Some of that is I can't really prevent many of these situations, and the other is that I really don't like that I'm so sensitive to changes in food intake. It really pisses me off! It seems so much less rational than an actual event to set off the ED.

Yet there you have it- the ED is the ED and my triggers are my triggers. It's not like one is "better" or "worse" than any other, and it's not that one trigger will only set off a benign relapse and another will be an utterly wretched relapse. So much of my relapse prevention planning has been coming to learn what my triggers are and accept them at face value, without judgement.

• not adding milk to my coffee
• avoiding mealtimes
• hiding food
• exercising in secret
• not taking a day off from exercise
• lying about what I've eaten (yes, even little white lies count!)
• ongoing insomnia (it might be the ED, it might be something else, but lack of sleep is one of my big triggers!)
• counting calories
• visiting calorie count and/or diet websites looking for tips/information
• purging
• subsituting candy for more nutritious food
• drinking calorie-free beverages instead of eating
• deliberately limiting calorie intake
• feeling cold
• extreme surge in anxiety and depression in conjunction with any other red light sign
• extreme fatigue (again, it might not be the ED, but it does need to be looked at)
• mentality of "I can't recover so why bother"

Technically when you're driving and you see the light turn from green to yellow, you're supposed to slow down and then stop. Yeah right. I don't know about you, but many times when I see a yellow light, I hit the gas and try to cruise through before the light turns red.

For most of my eating disorder, this was how I operated. I saw the warning signs of relapse and I just hit the gas on the eating disorder. Some of this was rooted in the basic neuropsychology of an eating disorder--that whole viscious cycle thing. But some of it was the fact that I really did think I could squeak by the need for more intensive treatment and recovery work if I just timed everything right (and drank enough water before weigh-ins).

Clearly, that hasn't worked out very well.

When I wrote my previous relapse prevention plan and identified my yellow light signs, I was still rather ambivalent about recovery. So my yellow light signs should have been my red light signs and my red light signs should have been flashing lights and sirens. Besides the ambivalence about recovery, I was also a little unprepared for how easily, quickly, and strongly the eating disorder can take over. I (not very wisely) thought I knew enough about eating disorders that I didn't need to be all that worried, right?

A false sense of security is one of the EDs greatest weapons.

Yellow light signs are different than prelapse signs because they have more to do specifically with the ED. Not that they deal solely with ED behaviors, but for me, most of the upticks in ED behaviors come after a time of increased anxiety/depression (although it took me years to figure out that the uptick was in response to this increased anxiety/depression). Not always, which makes the increased anxiety more of a "prelapse" than an actual sign of relapse.

The yellow light signs are, for me, a sign I need to slow down and take a good, hard look at what is going on. They're signs that the ED is returning. If you'll forgive another car analogy, they're like the "check engine light." Your car might be running just fine, but the light is usually an indicator that something is about to go rather wrong.

My Yellow Light Signs are:

• increased paranoia about food (not trusting what others give me, etc)
• looking up nutritional information on the internet
• feeling like everyone is watching every bite I take
• exaggerating what I ate
• rigidity around exercise
• need for precision with measuring food
• extreme irritability
• gnawing doubts about my ability to recover (this is a precursor to the "F*ck recovery!" stage)
• procrastinating on returning messages
• desire to run away and/or hide from life
• urges to purge or hide food

What I found hard with identifying these signs is that my relapses tend to simply leap straight from 0 to 100 with nary a stop in between. I can go from green light signs to red light signs in less than a week. So identifying the yellow light signs is both tricky and crucial. The other issue I struggle with is identifying and acting on the warning signs. Often, I tend to downplay the seriousness of the problem even in my own mind, and so I delude myself into thinking that it will go away or that I can handle it on my own. It's hard. It's damn hard, and I'm not always super-confident in my abilities and judgement on the subject. Which means I am having to accept a big dose of humility in learning how to manage my ongoing recovery.

On Saturday, I shared some of my recovery green light signs, which was a list of thoughts, behaviors, etc, that were indicating my recovery was going along well. I am going to share my yellow light signs (warning signs of relapse) and red light signs (take action now, do not pass go, do not collect $200). But somewhere in between green light and yellow light are the signs of prelapse. If yellow light are the signs preceding a relapse, then prelapse consists of the signs before the signs.

I realize I haven't really defined some terms, so that we all know we're referring to the same idea, here are some (brief) definitions:

lapse: a one-time return to ED behaviors. It means you purged once, or skipped a meal, and so on.

relapse: an ongoing return to ED behaviors.

prelapse: the indication that you might be be heading for a lapse or at high risk for a lapse. It doesn't mean a return to ED behaviors.

Some of my prelapse signs are very related to the eating disorder (urges to skip meals, increase in body dysmorphia) but many of them aren't. Although I'm not sure that eating disorders have nothing to do with food, many of my vulnerabilities to anorexia and to returning to anorexia have nothing to do with food.

Here is my list of prelapse signs:

• preoccupied with food/eating
• avoiding friends and family
• urges/compulsions to overexercise
• increased rigidity in life and activities
• thoughts/urges to skip meals
• increased preoccupation with body image
• lingering sadness and depression
• feelings of restlessness
• return of OCD behaviors
• difficulties sleeping
• intense feelings of guilt and worthlessness

Many of the things on my list of strategies to deal with these prelapse signs are similar to what I wrote in an earlier post on identifying your triggers.

• deep breathing
• reduce stress
• ensure adequate sleep
• make plans with friends and family even if I don't feel like it
• snuggle with Aria
• work on creative projects (crochet, jewelry, etc)
• practice opposite action (watch a funny movie when I'm feeling down)
• eat several tablespoons of peanut butter before bed
• practice self-compassion
• increase appointments with treatment team
• BE HONEST about urges

Please share some of your prelapse signs in the comments section!

• flexible about meals (quantities, portions, etc)
• minimal anxiety eating at restaurants
• in regular contact with friends and family
• exercise no more than X days per week (I don't want to trigger anyone, so I edited the number)
• not spending hours doing grocery shopping
• not letting body dysmorphia unduly influence clothes choice
• able to eat without knowing precise calorie counts
• no body checking
• experimenting in the kitchen
• engaged in reading, other activities
• minimal ED thoughts, no strong urges to engage in behaviors
• tracking my food intake via my meal plan (NOT counting calories, fat grams, fiber, sugar, etc)
• normalized consumption of sweets

Part of any good relapse prevention plan should be some ideas for alternate behaviors or activities for when you feel the urges to engage in ED behaviors. Over the years, I've come to realize that this list isn't always enough. When I'm really struggling with urges, some of the suggestions on the list can seem asinine--feel like purging? Knit a scarf. There ya go.--and sometimes you would be happy to knit a scarf if only you had some yarn and a pattern. But you don't.

Enter the Emergency Kit.

My kit is an old shoebox that I decoupaged in treatment and inside I keep my list of alternate behaviors, and I also keep some supplies for these alternate behaviors. Some of these supplies include a bottle of bubbles, a skein of funky yarn, a rubber ducky, some meaningful mementos, phone numbers of friends/family, and a $5 Starbucks gift card. I also have a really hard jigsaw puzzle, but that's in my closet, not the box. When I'm really wanting to act out on the eating disorder, it's all well and good to think that standing on the back deck and blowing bubbles would make you feel better, but you also need to know where those bubbles are and (this is just as important) have them available for easy access. At these times, I have minimal frustration tolerance, and rooting through drawers and boxes is not going to be helpful. Hence the Emergency Kit. Everything is all together and easily accessible.

My list of alternate behaviors includes the following:

• crochet
• blogging
• sudoku
• reading
• heavy-duty cleaning
• snuggling with Aria
• listening to my iPod
• taking a shower
• looking at travel websites
• lighting candles
• take a nap
• deep breathing

These alternate behaviors are also alternates for other less-than-helpful behaviors, such as marinating in my own anxiety and that depressive perseveration. The list originally came from the distress tolerance module of dialectical behavioral therapy that I worked on in treatment. I initially targeted it towards ED behaviors, but I found it helpful in pretty much any situation. I've added to it over the years, and crossed out a few items.

Ditto for the emergency kit. I have a few items I'd like to add, such as Silly Putty, Play-Doh, and Legos. But the contents have remained remarkably stable over the years (this either means I picked good items or I'm frighteningly consistent).

The other key factor is to actually use your emergency kit. I used to tell myself that this wasn't a real emergency and I should save the yarn, bubbles, whatever, for an actual emergency. I've had to tell myself, over and over, that any thoughts of turning to my emergency kit are an actual emergency. I wasted my money if all the stuff does is sit there and collect dust.

What sorts of items do you want to include in your emergency kit? Share your responses in the comments!

Ah yes. Identifying triggers. When I was deep in the eating disorder, pretty much everything triggered eating disordered thinking. Even in early recovery, much of that persisted. A glance at a magazine could trigger a storm of self-loathing. The barest hint of reproach from another person could send me spiraling. And any anxiety-provoking situation would leave me fantasizing about slashing my food intake and increasing my exercise.

Things have improved since then, but there are still any number of situations that amplify the eating disordered thinking and make me ever more vulnerable to relapse. Some of the point of identifying your triggers is to anticipate when you might need extra support. The other point of this is to make what I like to call a "mitigation plan" (it's a term I used when I was working in emergency preparedness, a career move that gave me many ideas into relapse prevention planning) so that you can survive the situation with as little lasting damage as possible.

Here is a (partial) list of my triggers:

• physical illness that affects eating/appetite
• seeing people running/exercising
• moving
• learning of a friend's relapse or weight loss
• weight gain
• new job
• feeling like I don't measure up
• clothes shopping
• getting off my schedule (ie, traveling)
• increase in depression
• increase in anxiety
• financial stress

Some of these triggers can be avoided, many of them cannot. Similarly, some of these triggers can be anticipated, but many cannot. Given that we can't avoid these triggers and we can't anticipate them, what else can we do? Like I did when I worked in emergency preparedness, I had to develop a plan (the mitigation plan) to help deal with them.

I created a general "mitigation plan" for all of my triggers and made certain additions as necessary to fit each particular situation.

My trigger mitigation plan looks like this:

• utilize support system
• increase frequency of therapy appointments
• compare and despair: I am doing the best I can at the moment
• stay to my specific schedule of meals and snacks no matter what
• BE HONEST about urges
• relapse is always there for me- I don't need to act on my urges right this second. I can wait and use my wise mind to think it through, and solicit feedback from others
• distance myself from negative people
• schedule meals and activities with others
• my exercise and eating plan are right FOR ME; it doesn't matter what other people are doing
• relapse only means more clothes shopping so don't go there

Some of these plans are appropriate in a wide variety of situations while others are more specific to certain triggers. The idea is to have a plan that is flexible and can be adapted to a variety of situations but still provide enough guidance on what needs to be done when the going gets tough.

Knowledge is power, they say, and in the case of relapse prevention this is definitely true. The phrase "forewarned is forearmed" is certainly apropos. If, for example, you can anticipate a trigger (maybe having to meet with a difficult family member) then you can start using your mitigation plan even before all hell breaks loose. Even if you can't totally prevent hell from breaking loose, at least you can contain the damage.

I'm starting this relapse prevention series by going back to the (very) basics. One of the major points of relapse prevention is to anticipate some of the difficulties you might have and create a plan for how to deal with them so that they don't trip you up too much. I think there's another aspect of relapse prevention planning that doesn't seem to get as much attention: assessing your strengths. What can you call upon when the going gets tough and the recovery gets tougher?

Together these strengths and weaknesses will provide a framwork for your relapse prevention plan.

Here is the list I wrote for myself:

Strengths

• good support system
• good treatment team
• good insight
• motivation to get/stay better
• can draw upon a wide range of skills

Difficulties

• body dysmorphia
• loneliness
• anxiety
• perfectionism
• putting insight into action
• dealing with change

After I made these lists, I then took each one of these difficulties and made a specific list of how to deal with these issues without using the eating disorder. I'll share the list I made for dealing with body dysmorphia, so I have something concrete to turn to when I have a "fat attack."

Plan for body dysmorphia

• focus on what my body can do rather than what it looks like
• participate in sports or dance vs. all solitary exercising
• repeat mantras: My body is healthy and healing at this weight.
• continue CBT work on addressing body dysmorphia
• "objects in mirror are smaller than they appear"
• talk/share my feelings on body dysmorphia and what else is going on
• accept the fact that I still have body dysmorphia and move on
• remind myself: Losing weight won't solve anything. The ED is a short-term solution to a long-term problem

This list isn't going to be the be-all and end-all for dealing with body dysmorphia and relapse--the issue is a pretty major one for me and this list doesn't even come near to covering it all--but it's a start.

Tomorrow, I'll look at another aspect of relapse prevention: Identifying Triggers

I've been working with TNT on developing my own personal, handy-dandy relapse prevention plan. It's far from the first plan that I've worked on, but it's the first detailed plan that I've worked on.

I've gotten emails and feedback on my blog about the need for better relapse prevention planning, and so I thought I would turn my therapy homework and your requests into a blog series on relapse prevention.

I have some idea of what I want to cover, but I also want input from you to see what issues you would like to see covered. It can be mundane--often the things that trip us up are pretty mundane. I can't guarantee that I will cover everything, but I will do my best.

Stay tuned for the first post later today!