The influence and importance of biology is an interesting and controversial topic in the field of eating disorders.  When I was first diagnosed with anorexia ten years ago, the debate centered more on if biology was involved.  Now, it's pretty widely accepted that biology is a factor in eating disorders. The question that remains is how important is biology.

We don't have percentages.  No one can say that biology is 75% important, and environment is 25%.  Every person I have met with an eating disorder has at least one (and often several) tick marks in each category.  For me, in the biology category, I have

• impaired set-shifting
• anxiety
• perfectionism
• depression
• loss of appetite under stress
• temperament traits of harm avoidance, low novelty-seeking, high persistence

In the environment category, I have

• thin-is-in culture
• tried to lose weight
• teased (weight was among those topics, but not always the focus)
• achievement-oriented culture
• fat phobic environment

So, yeah.  It's not an either/or question, and it frustrates me to no end that so many people think that it is.  This isn't a game of Red Rover, Red Rover.  You don't need to pick sides.  In fact, you can't pick sides because you can't separate genes and environment.  It doesn't work that way.  Environment affects what your genes do, and your genes affect what environments you seek out.

Even the researchers who specifically study the neurobiology of anorexia don't say that culture is irrelevant.  They say (and I would agree) that culture doesn't cause eating disorders.  But that's far from some sort of robotic, reductionist view that life is just some biochemical soup.  The study of biology in relation to eating disorders has added volumes to our knowledge about the subject.  Biology is a powerful thing.  We shouldn't take it for granted, nor should we scoff at it as an easy way out.  If it's biology, you're either stuck with it, or you just take a pill and All Better!

Which is really funny because none of the researchers I know think anything even close to that.

This is why I was really chagrined to read this article on addiction and eating disorders.  It starts as follows:

These days researchers and writers like to boil all maladies down to the biochemical level. The medicalization of all things sure makes life simple: if it’s just faulty brain chemistry, then there’s eventually going to be a pill for it.


But there is no pill to erase the feelings that grip Katherine’s gut when she walks into her childhood home for Thanksgiving. The Marlboro stench of the old curtains, the worn areas on the carpet, the heaviness on her mother’s hips and in her voice, the back bedroom filled with unopened boxes from QVC shopping binges, her father’s palpable misery about his job, the bathroom where she first learned to throw up…

I will say that when neurobiological studies were first published maybe 20 or 30 years ago, people probably did hope that we could take a pill and cure all of our mental ills.  We've gotten a lot older and a lot wiser since then.  No one remotely believes that you take a pill and bye-bye eating disorder (or depression or anxiety or whatever).  Medications can help, but they're not a cure-all.

Secondly, there's a growing body of research related to PTSD of what happens to the brain during stress and during traumatic events.  Psychologists have long known that environmental cues are a huge factor in relapse in drug addiction.  It's environmental (you see or hear something that reminds you have your drug use) AND it's also biological (this triggers memories and cravings and dopamine and what have you).

Memories are powerful.  One of the times I was most powerfully triggered was when I spoke with the boss I had from when I was most acutely ill.  I was shaking when I hung up the phone.  I wanted to throw up.  I never wanted to eat again.  Her voice immediately took me back to that place.  It's another reason I avoid the gym.  Memories of my exercise addiction trigger cravings for more exercise.

Researchers are looking for ways to help the brain unlearn the traumatic response to an event, and some of these methods may involve pills.  But a pill isn't going to cure PTSD, it's not going to cure anxiety and depression, and it's not going to cure eating disorders.

Walter Kaye is probably the top neurobiologist in the eating disorder field.  And he doesn't give out pills at this San Diego clinic.  He delivers therapy.  Therapy changes the brain.

Biology isn't a dirty word.  It's not the lazy way out, and it's not ignoring or neglecting environmental influences.  And it is important.

In my Twitter timeline this afternoon (you do follow ED Bites on Twitter, don't you?), I read the following tweet from the magazine Psychiatric Times, by way of The Canyon treatment center.

Trauma, rage, depression, codependency other issues may be at the root of most eating disorders.

The tweet linked to this article here: Eating Disorders' Underlying Issues.

I'll admit that any PR article has my journalist's bullshit radar on high alert. Remember, a press release is trying to sell you something--in this case, a treatment center, but they can also be selling a viewpoint, product, or idea. But press releases aren't going anywhere, and if you take them with a grain of salt, you'll usually do okay.

What made me twitchy was the use of the words "underlying issues" and about stuff being at the "root" of eating disorders. It's not that I don't think pre-existing and co-morbid conditions are irrelevant to eating disorders--far from it. They absolutely play into how and why someone might stumble into an eating disorder and then stay there.

But that doesn't mean that these issues are an "underlying cause." At the root of an eating disorder is an eating disorder. For whatever reason, a person with an eating disorder processes information about food, eating, exercise, and often weight in a very different way. To them, starvation may anesthetize anxiety or depression. Or maybe binge eating and purging helps alleviate social discomfort. If this didn't happen, you wouldn't have an eating disorder.

I'm not against addressing underlying disorders--much of the work I'm doing now is to address my anxiety issues. This untamed anxiety really drove my eating disorder. Starving and overexercising gave me relief. But addressing these "underlying issues" without first addressing the eating disorder is like trying to fill a bucket with a large hole in the side. It's kind of futile.

Refeeding alone isn't enough. Sitting someone with an eating disorder in front of a plate of food and just saying eat isn't enough. ED'd people need lots of support. Remember, the eating disorder does have some perceived benefits. Saying "Go home and eat a sandwich" isn't going to cut it. But a crucial part of treatment involves getting over your fears of eating that sandwich.

I always resented people digging through the midden heap of my life, looking for the "root cause" of my anorexia. The rage I had was primarily starvation-induced (even the men in Key's Starvation Study had anger outbursts). I didn't have any traumas, and therefore I figured I couldn't really be sick because I didn't have a reason to be. And so I spent years trying to find a cause to my eating disorder to the almost complete exclusion of addressing my actual illness.

If you have a tumor, you don't want to begin treatment until you figured out the underlying cause for your cancer. This isn't to say that it's not important to take a good look at your environment and remove any carcinogens, but that's not a reason to delay treatment.

I'm not saying that issues of trauma, bullying, depression, etc, shouldn't be addressed in treatment. In fact, I think they must be addressed to ensure full recovery. But that's not the same as saying that these things are an "underlying cause" of an eating disorder.

I hate being weighed. It makes me freaky anxious and I just don't like it. I worry that I might have gained, which will make me hate myself. I worry that I might have lost and then everyone will freak out on me. The ED part of my brain still sees maintenance as some sort of abject failure because I should be losing weight, not maintaining it.

It probably sounds pretty paradoxical that I find the concept of being weighed at my therapist's office to be reassuring and helpful. Not because I take comfort in being weighed--I most certainly don't--but because I find it helpful to know my weight and know that it is staying where it needs to be.

My first therapist never weighed me, although it didn't really matter all that much because I was weighing myself 80 bazillion times a day anyway. I ended up in the hospital soon enough because my physical deterioration was making my low weight almost a secondary issue. My second therapist used to weigh me, back to the scale, each week and then she slowly phased that out. Ditto for my dietitian. That left me to my own devices for quite some time, and it wasn't pretty.

Not being weighed felt nice at first, because I really do hate being weighed. It's kind of embarrassing, like someone knows all of your dirty little secrets. The problem was that the ED had a field day. I couldn't self-regulate around food. I would overeat, and then restrict and overexercise. Whether this would have showed up in my weight is unclear, but the lack of weighing added one more way for me to hide the seriousness of my ongoing eating disorder.

With my relapse last year, it was back to the weekly ritual of being weighed. I was weighed with my back to the scale so that the weight gain wouldn't freak me out. This was no doubt a wise move, as I'm reasonably confident that I really couldn't handle knowing the number at that point in time. However, TNT has a very different philosophy about weighing (namely that it's just a number and there's a time when you have to get over it) and so I started actually knowing my weight. After an initial freak-out, the actual number ceased to be such a huge deal. I still detest that number, think I'm a whale, etc, but the number itself doesn't provoke as much anxiety as it once did.

Now that I am in recovery and doing well, I'm still weighed by TNT, although only every other week. It works out well- I get a respite from the grueling scale-induced anxiety attacks but TNT is still monitoring my weight closely enough that the ED can't really get out of hand. My parents and treatment team are (not surprisingly) more worried that I will start losing weight again. Since I have the eating disorder and am therefore not that rational about my weight, I mostly worry that I will once again start gaining. Seeing my weight stay exactly the same week in and week out gives me the reassurance that my body isn't going to flip the hell out at an extra cupcake, and it reassures my parents that I really am taking this whole recovery thing seriously.

There's another interesting variable that my weight gives TNT: an insight to my psychological state. Bouts of the stomach flu aside, usually a drop in my weight means an increase in anxiety and ED symptoms. There's no clear cause and effect (did the drop in weight increase the ED thoughts or did the ED thoughts cause the drop in weight? I think both are true) but the fact that my last therapist pushed for a higher weight and then insisted I stay there (despite me calling her a meanie and much, much worse) has given me much greater psychological stability. The slightly higher weight (5-10 pounds) is the price I have to pay for a hint of peace of mind. But the opposite would have been a Faustian bargain: a weight I "preferred" but an ongoing, never ending, ultimately losing battle against the ED. Seeing my weight every other week is a reminder of that icky number, but it's also a reminder of my renewed peace of mind.

I like the fact that someone is monitoring my weight even though I really do hate getting onto that scale. Waiting for the little slide weights to settle themselves is like waiting to hear a verdict: it's long and agonizing but it probably really takes no more than 10 seconds. I'm getting used to my new weight although I still don't like it. I prefer knowing the number to not knowing it because at least if I know it, I'm not imagining having reached a four-digit weight overnight. Which makes the entire situation one massive paradox: hating getting weighed, liking the security of being weighed; hating what I weigh, liking to know that awful number rather than leave it to the imagination.

Since when did an eating disorder ever make sense?

On Facebook today, I read a status update from a friend of mine who asked us to honor the memory of a girl who died from her eating disorder five years ago today. Which is tremendously sad, and I hope that her story will help others pursue the treatment they need and deserve. But that's not the point of my post. The point of my post is that my friend said the girl died from "the pressure to be thin."

No. She died from an eating disorder. Big difference.

I didn't comment on my friend's Facebook status because I didn't want to take away the importance of honoring this girl's memory, nor do I like Facebook arguments because I can't be concise. Also, even despite my friend's statements, we still remain friends and this hasn't changed that.

But "the pressure to be thin?" Seriously?

I'm not saying that the pressure to be thin is irrelevant to eating disorders because it does play a role in some people's triggers, and certainly in obstacles to recovery. But an eating disorder isn't a pathological and deadly response to the pressure to be thin; it's an actual mental illness that involves a life-threatening inability to self-regulate around food. Furthermore, by saying that an eating disorder is "caused" by the pressure to be thin, it excludes all of those with eating disorders who don't have body dysmorphia, those who developed EDs in cultures that didn't place a high value on thinness, and those who developed EDs long before there was a widespread cultural pressure to be thin.

So. Now that we've got that out of the way...

For most of the people I've talked to with eating disorders, being thin is usually the least of their motivators when in the thick of it. I did have a phobia of gaining weight (a massive phobia of weight gain, for that matter) but it wasn't a cultural pressure. It was me. It was from the eating disorder--I didn't feel that pressure before, and I don't really feel it now. I didn't decide to lose weight to look like a model. It was an attempt to eat better, exercise more, maybe lose 5 pounds and pull out of the awful depression I was in. Without my predisposition to anorexia, I'm fairly confident everything would have stopped there. But it didn't.

Did I use our culture's obsession with dieting and thinness as an excuse while in my eating disorder? Yes. And to some extent, it would have felt more sane to tell myself I just wanted to look like some famous waif than to actually understand that I was terrified of food and eating. I never thought of my eating disorder as just "being on a diet" or "trying to be skinny." It was just this single-minded obsession to eat less and exercise more that really had no explanation.

I did think that if I could lose enough weight then maybe I would stop hating what I saw in the mirror. And I'm not going to say that culture had nothing to do with that, but I was well aware that everyone else saw me as too thin. It was my own messed up standards that didn't really kick in until after I had already started walking down the yellow brick road to anorexia. In other words, the intense body hatred was as much a result of my eating disorder as it was a cause.

Saying this girl who died from "the pressure to be thin" minimizes the true, serious nature of eating disorders. It takes a very complicated issue--the interplay of nature and nurture--and so over-simplifies it that the truth is lost. Not that feeling pressure to be thin has nothing to do with eating disorders, but to say that this pressure to be thin is the same thing as an eating disorder is a rather big misstatement.

I received a flurry of feedback and comments on my post about Anorexia Mythbusting, and the discussion managed to be passionate and respectful. Which just goes to show that I have the best readers ever. The discussion was fantastic and engaging, and one comment in particular prompted me to do a follow-up post.

Earlier today, Jane (one of the co-chairs of the organization Maudsley Parents) wrote:

I wonder if a lot of the problem here is the word "cause." It seems to me like too simple a construct to be very useful. I find the genetic and neurobiological research on AN very compelling, but I'd be hesitant to say genes or neurobiology cause AN (maybe Radford or others would--I don't know). It seems to me more accurate to say they are responsible for risk. I really think the predisposing/precipitating/perpetuating model makes much more sense than saying, " X causes (or does not cause) AN."

Although I have a special interest in adolescent AN, I agree with Adria and Melissa other eating disorders (as well as disordered eating) merit consideration. Social influence might not be the same across eating disorders.

Humans like to look for "cause," myself included. We want to be able to answer why, to draw conclusions, to figure it out. But as Jane pointed out, the word "cause" as it points to a single factor--be it genetics, models, or mothers--is probably a little over simplistic. The predisposing/precipitating/perpetuating model that Jane mentioned is based on our relatively new understanding of the complex causes of many illnesses.

Take tuberculosis. It was originally thought that you got TB because you came from a bad family or you breathed in bad air. Even after the discovery of the TB bacterium, there was thought to be a simple cause and effect. You breathed in the bacterium, you developed TB. Except it's not that simple. Ninety percent of the people who harbor the TB bacterium in their lungs (after the initial infection, the body walls off the bacteria in the lungs) will never progress to clinical illness or transmit the disease to anyone else. So what's the difference between them and the 10% who do go on to develop clinical disease? Often, TB re-emerges at a point in a person's life when their immune system is weakened, and the bacteria can break free from their "jail" in the lungs. Many things can contribute to a weakened immune system, not the least of which is HIV or other severe infection, but factors also include severe stress and malnutrition. Assuming two people had latent TB infections in their lungs, and one was of a higher socioeconomic class than the other, the person who was wealthier would probably be less likely to develop TB simply because their immune system might have been in better shape. Furthermore, poor people are more likely to live in the types of close quarters that promote TB transmission, and so are probably more likely to inhale the bacterium in the first place.

Does poverty "cause" TB? No. But you can't study TB without realizing the effects of poverty. Just understanding the microbiology isn't enough. It isn't a simple matter of infection causes disease. The infection is a necessary but not sufficient aspect of TB. Vulnerability to TB infection doesn't just start with the infection (or the re-emergence of the infection). It starts with your access to food, with air quality, with a whole host of things that don't have anything to do with the actual bacteria.

It's similar with eating disorders. I would argue that the genetic predisposition is a necessary but not sufficient cause of eating disorders. You don't really see eating disorders in people without the genetic background, but the genetic background alone isn't enough.

So what the heck are these predisposing, precipitating, and perpetuating factors anyway? A good explanation of these factors comes from a continuing education course from the American Dental Hygenists' Association:

[Eating disorders are] considered to be developmental more so than mental. Therefore, predisposing, precipitating, and perpetuating factors are more useful to consider than actual causes.

Factors considered to predispose an individual to anorexia include female gender, family history of eating disorders, perfectionist personality, difficulty communicating negative emotions, difficulty resolving conflict, and low self-esteem. Precipitating factors associated with anorexia focus on developmental changes, such as sexual development and menarche in persons aged 10 to 14 years, which leads to a spurt in weight gain; independence and autonomy struggles in individuals aged 15 to 16 years; and identity conflicts in individuals aged 17 to 18 as they transition from home to college or married life. Perpetuating factors are those that maintain the eating disorder. Examples of these include signs and symptoms of starvation and coping strategies engendered by the eating disorder.

I personally would add illness, efforts towards "healthy eating," dieting, teasing, and other forms of trauma as precipitating factors. But I think this is a good breakdown of what these different factors are and what forms they make take.

A longer explanation (it's slightly dated as it was published in 1988) can be found here: Predisposing, Precipitating, Perpetuating, Professional Help and Prevention for Eating Disorders. This paper also wins the award for today's Best Use of Alliteration.

I promise you that I tried to find other analogies for this, but the best explanation I could think of was a cooking analogy. It's kind of like baking a cake: there are certain basic items that you need to make a cake (flour, sugar, baking soda, etc). You don't typically see anchovies called for in baking. Different cakes have different ingredients (chocolate birthday cake vs. flourless chocolate cake vs. chocolate cheesecake*), and even the same type of cake can have the same ingredients that vary in amounts (more sugar, less leavening). You can add frosting--or not. You can add filling. In the end, though, most cakes have a few staple ingredients that you combine and then bake in the oven. I don't make up a box of Betty Crocker yellow cake mix and expect to pull a Caesar salad out of the oven. It might be over- or under-baked, but it's still cake.

The different ingredients are the predisposing and precipitating factors- not everyone has exactly the same genetic or environmental experiences, but there are often variations on a theme. The "baking" part is where I see the precipitating factors becoming the perpetuating factors. Different ingredients, different baking times, different cakes...but they're still cakes. No one ingredient causes these cakes to spring forth into being (unless you count the baker). Flour doesn't "cause" a cake, nor does sugar, nor does flipping the oven on and popping in a pan.

When trying to figure out what went wrong with a recipe, I often zero in on something. Maybe the oven is on the fritz. Or the baking soda was ancient. Or I was a little short on sugar but hoped for the best. That doesn't mean that that is the only thing wrong with the recipe, just that I focused on one thing. So with eating disorders, focusing on our culture's expectations of beauty as a cause of eating disorders is a little myopic. So is focusing on just genetics and neuroscience.

And a total gold star to whoever made it this far and muddled through my hopeless analogies!

*Yes, I know cheesecake is essentially a custard, but it has "cake" in the name so I'm running with it for the purposes of this analogy.

Earlier this week on Twitter (do you follow ED Bites on Twitter? You know you want to...), I ran across an interesting article about why some antidepressants don't work in some patients. The article was published last week in the research journal Neuron and is titled "5-HT1A Autoreceptor Levels Determine Vulnerability to Stress and Response to Antidepressants." (Clicking the link will take you to the free full-text of the article.) I'll let the opening of the article's Science Daily press release explain the research for me:

An excess of one type of serotonin receptor in the center of the brain may explain why antidepressants fail to relieve symptoms of depression for 50 percent of patients, a new study from researchers at Columbia University Medical Center shows.

...Most antidepressants -- including the popular SSRIs -- work by increasing the amount of serotonin made by cells -- called raphe neurons -- deep in the middle of the brain. Serotonin relieves symptoms of depression when it is shipped to other brain regions.

But too many serotonin receptors of the 1A type on the raphe neurons sets up a negative feedback loop that reduces the production of serotonin, Dr. Hen and his colleagues discovered. "The more antidepressants try to increase serotonin production, the less serotonin the neurons actually produce, and behavior in mice does not change," Dr. Hen says.

Seeing as anti-depressant therapy hasn't shown much promise in the treatment of anorexia nervosa (although it does appear to help treat co-morbid conditions like depression and anxiety), this research could help with the development of new treatments for AN. It also seemed like a good a time as any to discuss the links between serotonin levels and eating disorders. In a 2005 review article, titled "Serotonin alterations in anorexia and bulimia nervosa," Walter Kaye wrote that people with either anorexia and/or bulimia showed alterations of brain functioning in specific neural areas:

Importantly, such disturbances are present when subjects are ill and persist after recovery, suggesting that these may be traits that are independent of the state of the illness. Emerging data point to a dysregulation of serotonin pathways in cortical and limbic structures that may be related to anxiety, behavioral inhibition, and body image distortions...Alterations of these circuits may affect mood and impulse control as well as the motivating and hedonic aspects of feeding behavior. Such imaging studies may offer insights into new pharmacology and psychotherapy approaches.

The serotonin/anorexia connection has been researched over the years (searching PubMed for "serotonin anorexia" gives you over 700 results), and the most recent thinking goes something like this. People with anorexia are generally thought to have unusually high levels of serotonin in their brains, and high levels of brain serotonin have been linked to anxiety and obsessionality. An old BBC article titled "Genetic clues to eating disorders" has a quote from Janet Treasure that explains some of the link:

People with high levels of serotonin are prone to anxiety. Dr Janet Treasure, director of the eating disorders unit at the Maudsley, believes this could be behind anorexic patients' ability to suppress appetite. She said: "In anorexia nervosa the drive to eat can be inhibited, but we know that in normal people who are starved they will kill each other and do all sorts of morally repugnant things, and eat all sorts of foodstuffs that you wouldn't normally touch.

"Yet that doesn't happen in anorexia nervosa, so there's some aspect of the appetite system that isn't working."

The unit looked at the biology of stress mechanisms, in particular the fight or flight response. This is where the body prepares itself for action when confronted by a stressful situation. Heart rate and blood pressure rise and two of what are usually humans' highest priorities, eating and reproducing, are put on hold. It is possible that anorexic people are chronically in an acute state of stress reaction - they are constantly in a fight or flight state of mind.

And by restricting food intake, people with anorexia can lower the amount of serotonin their bodies can make (serotonin is ultimately derived from the essential amino acid tryptophan). This actually makes people with anorexia feel better. However, the brain begins to sense the decreased serotonin production and tries to maintain homeostasis by increasing the number of serotonin receptors. Thus the brain is back at Square One, as it is producing less serotonin but is using the decreased amount much more efficiently. So restricting doesn't feel as good, and the (obvious!) solution is to eat even less. And thus that negative cycle is born and the anorexic becomes trapped by their own brain chemistry.

Refeeding would then increase the amount of serotonin in the brain before the brain has a chance to decrease the number of serotonin receptors. This could be the neurological equivalent of All Hell Breaking Loose and could very well explain why refeeding is so distressing, although I don't think there has been any formal research done on the subject.

In bulimia, the serotonin problem is reversed. People with BN appear to have much lower than average levels of serotonin in the brain, which may be temporarily increased by binge eating.* Purging increases levels of vasopressin, which can have a euphoric and sedating effect, thus making the binge/purge cycle addictive much in the same way that starvation becomes addictive in AN. The chronic low levels of serotonin in BN also explain why SSRIs can be effective at reducing the urges to binge and purge.

Of course, plenty of people cross over from anorexia to bulimia, and I haven't the slightest idea of how serotonin might affect that crossover. So many brain systems are thrown out of whack during an ED that I don't know an exact answer will ever be found.

*The story is, as usual, a little more complicated than this, but the basic idea is the same.

At an initial glance, a new study from the Journal of Consumer Research appears to have absolutely nothing to do with eating disorders. It wasn't about magazines or models or the purchase of diet products. The title of the paper had the rather bland-sounding titled of "Counteractive Construal in Consumer Goal Pursuit." That sounds as exciting as organizing my sock drawer. Rather, what caught my eye was the title of a news brief about the research titled "Resisting temptation is easier for those who exaggerate the threat."

And I thought, "Huh. That sounds a lot like what happens in eating disorders."

It sure does.

The authors of the research did four different studies, which they looked at to draw their conclusions. Two of those studies had to do with dieting and weight loss.

From a press release:

“Four experiments show that when consumers encounter temptations that conflict with their long-term goals, one self-control mechanism is to exaggerate the negativity of the temptation as a way to resist, a process we call counteractive construal,” the researchers write.

For example, in one study, female participants were asked to estimate the calories in a cookie. Half the participants were told that they have the option of receiving the cookie as a complimentary gift for participation and half were not. The results showed that consumers with a strong dieting goal construed the cookie as having more calories and being more damaging to the attainment of their long-term goal of losing weight.

{snip}

In [another] study, female participants entered a room that either had posters depicting fit models or nature scenery. “Participants who were exposed to posters depicting fit models (goal-priming stimuli) were more likely to exaggerate the calories in a tempting drink that they expected to consume later on, and consequently consumed less when offered the drink,” the authors write.

The relevance to eating disorders is obvious, even when you ignore all of the stuff about weight loss. That's not what I find the most interesting. The key words that leaped off the page at me were "resisting temptation" and "exaggerate the threat." For many people, temptation is temptation. Someone who is predisposed to an eating disorder, however, may be much more likely to view temptation as a threat. You can add me to that category. People with AN in particular are prone to asceticism, which Wikipedia defines as "a lifestyle characterized by abstinence from various sorts of worldly pleasures (especially sexual activity and consumption of alcohol) often with the aim of pursuing religious and spiritual goals."

Want something even more ascetic that renouncing sex and booze? Renounce food. If these things weren't considered somehow "tempting"--read any nutrition advice about the holidays and you'll see what I mean--then they wouldn't need to be renounced. Many people with AN struggle with including pleasurable things in their lives. I'm not talking about pleasure from a night with your latest order from Good Vibes and a pair of AA batteries. I'm talking about the pleasure of relaxing in front of a fire, leaving the dishes until morning, going to a party even though you have a paper due the next day. Little things. I don't find them alluring as much as I find them anxiety-provoking, perhaps because they are so alluring to me. The thought of holding up a bank doesn't cause me anxiety because I have no desire to do so.

So there we have the part about "resisting temptation." Now we get to the part about "exaggerating the threat." The all work, no play work ethic of mine gets its oomph largely from my fears of what will happen if I play. How can I relax when there are stories that need researching and writing? How can I leave the dishes until morning when there might be a bug problem? How can I skip working on my paper, which could mean that I do horribly, fail the paper, fail the class, fail out of college, and wind up living in a cardboard box?

Like I said, "exaggerating the threat."

I'm a veteran calorie counter. When I'm wrong about the calories in something (which I occasionally am, although after 10 years, there's not a whole lot that I haven't already looked up), it's because I grossly over-estimated the number of calories in something, not an underestimate. An extra bite becomes 1000 extra calories in my mind. And when you consider that food is anxiety-provoking to people with eating disorders, there's already that tendency to exaggerate how awful, fattening, and massively portioned a food was.

Besides my food issues, I am also terrified of spiders. I've whacked off several roaches, millipedes, centipedes, and other bugs I didn't take that good of a look at. I don't like these bugs, but I can at least get rid of them with some shred of self-respect. Spiders are another matter entirely. Even a daddy long-legs seems huge to me. I see one and I scream like a girl. The other girls in my dorm always asked me to be on spider patrol because I was a "biology person." All I could think was that I use a microscope, not a fly swatter. Spiders seem massive to me- a literal interpretation of exaggerating the threat.

So when food seems far more threatening than it is tempting, it's easy to see how avoiding food would become almost instinctual.