Consider this thought experiment:

Drop a person in a blender (since it's all hypothetical, go ahead and make it someone you don't like. Feel better? I bet you do!). Then, count all the total number of cells that are produced. Only one in ten of these cells will be human. The other 90%? Those are all microbes. If you look at the total number of genes in your human smoothie (NOT coming soon to a Jamba Juice near you), the numbers are even more skewed: only one in 100 genes are human. The rest are, again, bacterial. The total collection of all of these bacteria living in and on our bodies is known as the microbiome.

The idea isn't to gross out the card-carrying germophobes among us. But let's face it: we're just as much bacterial as we are human. Plenty of these microbes live on our skin, in our lungs and genital tracts. The mother lode of microbes, however, live in our gut. They are crucial to extracting energy from food, and these microbes are extremely sensitive to what we eat. Starving mice for just one day dramatically alters the composition of their gut microbes. Specifically, it decreases a type of bacteria known as Firmicutes. When researchers transplanted Firmicutes into the guts of lean mice, they rapidly gained weight (Crawford et al., 2009)

When it comes to eating disorders, there isn't much talk of microbes. There are the occasional papers from researchers like Sergei Fetissov about potential auto-immune responses in people with eating disorders, and some work on PANS (pediatric auto-immune neuropsychiatric syndrome) and anorexia, but generally, researchers haven't looked at the role of the microbiome in triggering or perpetuating an eating disorder.

Much work has been done in obesity research. Scientists have consistently found that people with a BMI >30 have different gut microbes than people with BMIs in the "normal" range. As well, bariatric surgery also significantly changes gut microbes as people lose weight, making them look more similar to the bacterial profiles seen in "normal weight" individuals. A more recent study in The ISME Journal proposed a microbiome diet: eating foods that would eliminate a type of bacteria called Enterobacter helped a person lose drastic amounts of weight in a short period of time (Fei & Zhao, 2012).

So how are microbes involved in eating disorders? No one really knows. Cindy Bulik has begun a study looking at this relationship, but the results still aren't in. Based on the studies above, it's reasonable to assume that ED behaviors (starving, binge eating, and/or purging) will have a significant effect on a person's microbiota. It still has to be measured, but I would bet a lot of money on it. The question is what do these microbial changes have to do with ED symptoms?

Imbalances in gut microbes in mice and rats have been found to alter patterns of risk-taking and anxious behaviors--something that also happens in people with EDs. They could also, perhaps, explain weight loss seen in anorexia and EDNOS. Maybe the initial restricting triggered a significant change in gut microbes that amplified the effects of malnutrition. Maybe they lacked a group of microbes that produced an important hormone regulating hunger and satiety. No one really knows.

One hint to the potential role of microbes in EDs comes from a study published today in the journal Science (Smith et al., 2013). The scientists studied the relationship between gut microbes and kwashiorkor, a form of severe malnutrition that occurs when a person doesn't eat enough protein. Of the 317 twin pairs from Malawi that the researchers followed for three years, half became significantly malnourished and 7% developed signs of kwashiorkor. Obviously, a lack of protein is crucial to the development of this disease but it's not the only factor as not everyone with a severely protein-deficient diet will develop kwashiorkor. Something else had to be going on.

First, the researchers treated twin pairs discordant for kwashiorkor (that is, one twin had it, whereas the other didn't) with "ready-to-use therapeutic food"- basically peanut butter on steroids. Twins with kwashiorkor had significantly different from nearby twins who (presumably) at pretty close to the same diet. The researchers found significant changes to the gut microbes in the ill children with the use therapeutic food. Discontinuing the therapeutic food caused a regression in the functioning of the gut microbes.

The kicker is this: when the researchers fed mice a standard Malawian diet and inoculated them with microbes from the guts of malnourished children, they rapidly lost weight and also developed kwashiorkor. This happened despite the fact that their diets contained adequate calories. One of the reasons that the researchers believed the therapeutic food is so effective at treating kwashiorkor is that it helped restore normal gut microbes.

To say what effect restoring normal gut flora will have on ED symptoms remains to be seen. Probiotics are a hot item, but much of the research is fairly overblown. There's definitely still potential there, and we need to know more about which populations of people are likely to benefit and which aren't. But it's an interesting idea, and I think we need to know a lot more about the role of the microbiome in the development and perpetuation of EDs.

In closing, a quote from scientist John Rawls in an interview with Scientific American:

“We are in the midst of a revolution of our ability to describe the composition and physiological potential of these bacterial communities...What we can begin to speculate on, though, are the different types of relationships that might be taking place. We know gut microbiota enhance our ability to extract calories from complex carbohydrates, which is clearly a mutually beneficial relationship. But it’s thought that all vertebrates have the capacity to digest and absorb other types of nutrients, such as lipids, proteins and simple carbohydrates, so it’s not readily clear how we could enter into a mutually beneficial relationship with bacteria with regard to those nutrients."

Obsessive-compulsive disorder (OCD) is one of the most frequently diagnosed psychiatric disorders in people with eating disorders. It is known to make eating disorders more severe and harder to treat, leading to a longer time until remission is achieved. Recently, more and more researchers are beginning to recognize the significance of the overlap between EDs and OCD, and are trying to develop specific treatments targeted at this population.

A 2004 study by Walter Kaye and colleagues in the American Journal of Psychiatry measured how frequently anxiety disorders (OCD is a type of anxiety disorder) occurred in people with anorexia and bulimia. They found that two-thirds of the ED sufferers had been diagnosed with an anxiety disorder at some point in their life. In general, the onset of the anxiety disorder pre-dated the ED by several years. Of the people with an anxiety disorder, 41% had OCD and 20% had social phobia (social anxiety). The problem, then, is very significant.

The gold standard in treating OCD is a form of cognitive-behavioral therapy known as exposure and response prevention (ERP). You can read more about ERP here. The idea is relatively straightforward: You create a hierarchy of the things you're afraid of that would normally provoke a compulsion. For someone who is afraid of germs, something lower on the list would be touching an unused surgical mask. Higher up might be touching a doorknob at a doctor's office or being coughed on by someone with a cold. Together with a therapist, you would begin to expose yourself to these anxiety-provoking situations and then not engage in any compulsions (like hand-washing) to relieve the anxiety. The point of this is to learn to tolerate the anxiety and that you're not going to die if you happen to inhale a few germs.

Some researchers are beginning to use components of ERP to treat food fears in EDs, especially anorexia nervosa. In a 2011 study in the International Journal of Eating Disorders, researchers at Columbia University first outline a behavioral model for AN that is driven by anxiety and obsessionality (see figure below; the caption is copied from the paper).

Figure 1. Model of Anorexia Nervosa. Traits of high baseline anxiety and obsessionality interact with environmental factors such that patients develop maladaptive behaviors, including food avoidance, and rigid eating patterns (or dieting practices), and they experience high levels of anxiety around eating. These behaviors are interrelated in that rigid dieting leads to increased anxiety about food and vice versa. These behaviors result in a diet that is low fat (low energy density) and limited in variety. This, in turn, promotes weight loss. The low weight state feeds back on the baseline traits and leads to increased levels of anxiety and obsessionality.

Anxiety about eating more and gaining weight consistently interferes with weight gain in AN and with interrupting the binge/purge cycle in BN. The idea is that recovery cannot and will not occur unless these fears are addressed. In a 2012 review article in the European Eating Disorders Review, psychologists hypothesize that one of the reasons family-based treatment is successful for many adolescents is that it forces these exposures. Since the patients can't (theoretically) choose what to eat, they can't choose to avoid "scary" foods. Parents are also coached on how to help stop other food-related rituals

A study published earlier this week addressed the issue of treating OCD and EDs, this time in a residential setting. Published in Cognitive Behaviour Therapy, the researchers treated 56 individuals with AN, BN, or EDNOS in an eating disorder program specific for individuals with co-occurring OCD. Of these patients, 41% were diagnosed with AN, 25% with BN, and 34% with EDNOS. Rates and levels of depression and OCD did not appear to vary by diagnosis. After treatment, the researchers found a significant improvement on scores for OCD, depression, and eating disorders, as assessed by a variety of surveys and self-reports. Patients with AN also significantly increased their body weight.

Which is all well and good, but the problem is that this study (nor any others that I'm aware of) compared the treatment group to anything. Other studies have shown that treating an ED generally improves levels of depression and OCD. Was the improvement seen in this study due to regular eating and the prevention of binge eating and purging? What effect did being in a structured environment have? Would these results have been different if the patients weren't treated for OCD? What about if their OCD was treated and not their ED? I realize that actually conducting a research study in that last scenario would be unethical, especially in a group that qualifies for residential treatment, but it's something that should at least be considered in the discussion.

Another question the researchers didn't factor in was the use of psychotropic medication. Eighty-nine percent of patients were on some type of psychiatric medication; the authors said they didn't control for this in their analysis since only 7% started on medication during their treatment. But they didn't mention how many patients' medication was adjusted, increasing or decreasing dose, or changing types and brands of medication. These things can have a significant effect on OCD and depression symptoms (although a recent study indicated that no psychotropic medications appear to be effective for AN)

As well, one of the researchers is the medical director of the treatment center where the research was carried out. This makes me a little skeptical of the results as a matter of course.

The researchers concluded that "Simultaneous treatment of OCD and eating disorders using a multimodal approach that emphasizes ERP techniques for both OCD and eating disorders can be an effective treatment strategy for these complex cases." But how effective? Is it better? How much better? How long did the results last for? There was no follow-up on any of these patients. Improving in a program is great, but the rubber doesn't really hit the road until after discharge.

This study is a start, but it's a small start. Co-occurring EDs and OCD can be very difficult to treat, but many people do go on to develop healthy and productive lives. We desperately need more resarch into the subject, but we need to start making comparisons to help develop the best, most effective treatment possible.

I was initially hesitant to do this interview because I don't think that publicizing these websites is necessarily a good thing (I know many people who first started visiting pro-anorexia sites after hearing about them on TV). That being said, ignoring an issue never works, so there you have it.

I think the interview went really well, all things considered. You can see my dorky Santa teddy bear coffee mug at some point, I believe.

{{Note, there is some talk of rather low calorie diets. If that sort of thing bothers you, then I would advise not watching it.}}

Lest you think I'm normal, let me provide you with yet another example proving otherwise. When my print version of the International Journal of Eating Disorders arrives in the mail, I totally geek out. Last month was no different. I've generally seen most of the articles before, as they are published online before they appear in the print journal, but I like sitting down on my couch with the journal and reading what's new.

What struck me about one particular study in last month's journal was not the study itself, but rather a reaction to it on Facebook.

What the study found

The researchers, which included recovering ER physician Suzanne Dooley-Hash, evaluated a series of 942 adolescents (ages 14-20) who showed up in the emergency room for any reason. They were given a computerized questionnaire, which evaluated (among other things) them for the presence of an eating disorder. The SCOFF questionnaire is below. Marking yes to 2 or more questions was considered positive for an eating disorder.

The researchers also assessed the patients' BMIs, and the presence of tobacco, alcohol, and substance abuse. Interestingly, BMI was associated with the presence of an eating disorder, but maybe not in the way you would expect. The teens with a BMI over 30 were actually most likely to test positive for an eating disorder- they were 3.2 times more likely to show signs of an ED than so-called "normal weight" adolescents.

Overall, the researchers found that 16% of the teens shows signs of an ED, and that nearly 30% of those with ED symptoms were male. Frankly, I think those numbers are a little high, as the SCOFF seems to evaluate a lot for disordered eating as much as a clinical eating disorder but that's outside the scope of this blog post.

But what's the denominator?

This, of course, brings me to the Facebook comment. In full, it read:

In the "International Journal of Eating Disorders" that came in the mail today I read a fascinating study on the prevelance and correlates of eating disorders among emergency department patients ages 14-20.  

They found that in a screening of nearly 1,400 patients that 16% screened positive for an eating disorder. That is much higher than the average of .5-1% for AN, 1-3% for BN, and 3-5% for EDNOS typically reported. In addition they found nearly 27% of those screened were male, much higher than the less than 10% typically reported. 

This supports much of the research we see that ED is on the rise, and that boys and men are just as much at risk.

Sad. We have much work to do.

 Here's the thing: the researchers were screening adolescents who were in the emergency room. This does not mean that that 16% of teens have eating disorders. It means that 16% of patients who were in this particular emergency room answered yes to at least two out of five questions on a survey.

Let me repeat: this study does NOT mean that 16% of teens have an eating disorder. Although the author of this comment didn't directly say this, it was sort of implied in the part where they said that "EDs are on the rise." One would likely expect that teens in the ER would be more likely to have an ED given the high levels of physical and psychiatric co-morbidity that they have. My guess is that people with EDs are much more likely to wind up in the ER than people without EDs. As well, teens are at higher risk for EDs and disordered eating, which further explains the high numbers.

Nor is this evidence that EDs are on the rise. I don't think there have been previous studies looking at the percentage of adolescents presenting to an ER who have ED signs and symptoms, so it's impossible to say whether these numbers are more or less than before. As well, the current research on the number of EDs in the US or elsewhere isn't all that great, so I'm rather cautious about saying whether EDs are on the rise. My bet is that we are certainly more aware of them, and so people might be more inclined to seek care (or be pushed into care, as the matter might be), but again, that doesn't mean that EDs are more common.

When evaluating these statistics, it's important to remember the denominator; that is, the portion of the population that the researchers are surveying. Here, it was adolescents in the ER. I bet you could find 100% prevalence on an inpatient eating disorders unit. We rightly should not be alarmed that so many people have eating disorders if these statistics were surveyed. Well, obviously people being treated for eating disorders almost certainly have an eating disorder.

The study is important in that it shows that ER docs can play an important role in identifying EDs. Most of them have their heads too far up their asses to actually do anything about it, but it is good and useful information. I don't like the SCOFF survey (like, at all), but it is quick and dirty, so I understand why they might have used it. Other than that, I think the study is very useful, but we all need to be careful how we interpret and talk about these results.

I turned in my book manuscript draft in mid-February. Then I went on vacation. Last week, I came back and faced down a migraine. The last week has been harder than I thought it would be. My therapist mentioned that this might be the case, especially since I have a history of what I like to call post-adrenaline depression.

I hated final exams at school. I was a stressed-out basketcase. I rarely slept, couldn't eat all that well from anxiety (even before the ED...my love of snacking on pretzels helped stem the weight loss), was usually sick with a cold, and was irritable, moody, and generally not fun to be around. But my need to keep myself together in order to take the exams usually kept things from getting ridiculously out of hand. My myopia saved me, in a sense. After the exams were done, despite being uber-glad that they were over and I could read for fun! and sleep! and drink something that wasn't espresso! I almost always plunged into a depression afterwards. Maybe depression wasn't the right word. It was more like a serious funk--my mood dropped, I was apathetic and unmotivated, and, horror of horrors, bored out of my mind.

The last week has pretty much been a repeat of that. Not quite as serious because bills need to be paid no matter how much I (don't) want to work, and I got a couple of extra projects from one of my freelance places, which also helps. Productivity is my antidote to despair.

Along with this funk came a bit of decline in my eating. It was thrown off first by the end of the book-writing period in which things just got chaotic. Not restrictive per se, but I didn't have the time, energy, and brainpower to take the time I normally would in planning and preparing meals and snacks. I did really well during my vacation, eating responsibly and mostly not too little or too much. Then the migraine hit and I didn't eat nearly what I needed to for that day. I didn't do quite as bad as I initially feared when I tallied everything for the day, but there was a definite drop. The next day, I did eat what I needed but felt terribly guilty. And so the passive restricting began, followed by the active restricting.

It wasn't super severe, especially in comparison with some of the crazy stunts I've pulled in the past. My weight didn't massively go down. Mentally, though, I was having a rough time yesterday. Depressed, cold, apathetic and terrified of everything. Which is kind of what snapped me into action. I texted my therapist and we worked out a safety plan and I'm trying to get back on track. I did a full day of meals today and most of the day yesterday. I was horribly anxious this morning, but I'm pushing through it and it's lifting, mostly.

I have a busy rest of the week planned, which will help, since business helps make the ED stuff more obvious (I don't have the brainspace or time to obsess or engage in behaviors). It also gives me something to think about besides calories and existential anxiety.

So...that's where I am. Regrouping and pressing on.

Most of you have probably noticed by now that it's Eating Disorders Awareness Week. For the first few days this week, my Facebook feed was inundated with message about loving your body and talking back to the media, and so on. It was like being at a high school pep rally, only about not wearing lipstick! and accepting our natural beauty! and loving our bodies!

I don't really like pep rallies, if for no other reason than I really don't do peppy all that well.

Rallying people and getting them motivated are great. Most of these war cries have to do with preventing eating disorders: that if we label digitally altered advertisements, we will decrease eating disorders. Or that people need to accept their natural sizes, which would eliminate eating disorders. They're nice thoughts, and they seem like really good ideas. It's why they have so much traction. People without eating disorders can relate to not liking how they look. They can relate to looking at beauty magazines and then feeling seriously ugly. They understand about dieting and wanting to be a Size Negative Eleventy Billion but not being able to lose those last XX pounds. Cindy Bulik calls this the "I just wanna look like a model" model of eating disorders.

The problem is that eating disorders aren't just extreme diets and treating them as such gets us nowhere. Writes Autumn Whitefield-Madrano, a recovering (?) eating disorder patient:

I just know that by the time I was discharged from Renfrew, I’d finally begun to learn that my dissatisfaction with my body wasn’t causing my eating disorder; it was merely a symptom of my disease, like restricting my food intake or binge eating...I’d begun to understand that loving my body wasn’t the point. The point wasn’t even to like it. The point was to learn how to eat.

I personally find body image--how the brain figures out what we look like--a fascinating neuroscientific and philosophical issue. My own body image issues long predated my eating disorder, but they didn't have anything to do with lipstick or models.My brain had a hiccup in figuring out what size I really was, likely due to problems in the insula and somatosensory cortex. Ridiculously altered images don't help, but they weren't a cause.

Others take a different approach towards eating disorders prevention. If we can educate people about how dangerous and pointless eating disorders are, then maybe people won't start. It's an attitude I had myself for a while, and the well-meaning philosophy feeds into tell-all newspaper articles and discussions about just how few lettuce leaves you survived on at your worst.

I never ceases to astound me just how many people give a shit about that sort of thing.

Except that this type of thinking essentially posits that eating disorders are choices, or voluntary behaviors. Perhaps that first step can be, I don't know. The problem is that most people who take that first step don't think they're going to develop an eating disorder as a result. So telling them that eating disorders are dangerous is kind of pointless, since they're not going to get an eating disorder from adding a little bit to their athletic training or cutting out junk food or whatever. By the time they have an eating disorder, it's too late.

To wit: a recent study on weight history in bulimia was just published, and researchers found that women suffering from bulimia ultimately gained weight as the result of their disorder. The Atlantic magazine wrote:

"Most patients lose a lot of weight as part of developing this disorder, and all dedicate significant effort, including the use of extreme behaviors, to prevent weight gain," said researcher Jena Shaw. "In spite of this, we found that most women also regain a lot of weight while they have bulimia," she continues. Maybe tell that to those kids with their pro-bulimia "ana-mia" Tumblrs?

{{Emphasis mine.}}

Nice thought, but it probably won't work to actually prevent an eating disorder. It's like telling someone who's sad to cheer up lest they get depression, or working to prevent bad moods everywhere! (Like pep rallies, unbridled optimism also makes me stabby, so I'm not sure I could tolerate this world for long...)

I'm not against the prevention of eating disorders, I'm just not sure that we have any clue how to do it yet.

I remember going to a therapy appointment quite a few years ago, flinging myself into the chair and promptly launching into a ten-minute-long tirade about how fat this complete idiot was making me. Didn't she see how huge I was? And she still wanted me to gain weight?!?

After I came up for air, my therapist looked at me and said with a voice that can only be described as overly saccharine, "Now, Carrie, we know that bad body image really isn't about how we look. Why don't you tell me what's really going on."

The reframe sent me further into a rage. Don't patronize me, I said. I'm feeling fat because I am fat and that's it. There's nothing more to it. Period. End of story. So why don't we talk about what we're going to do about my need to lose weight now that you've porked me up.

And so on. The session would not be classified as "productive."

With time, maturity, and proper nutrition, I've come to realize that my therapist had a point. I remembered her point today, when my work schedule can only be described as a game of Whack-a-Mole on meth. I'd send one email, and other editor would ask for art. I'd send some potential images, do the changes on the previous email. While making those changes, editor #2 would write back and say those images don't work, do you have any more? So I'd search for some, and then editor #1 would write back and...well, you get the idea.

I was stressed and on edge, almost ridiculously so. Perhaps not surprisingly (to my ex-therapist, at least) the feelings of body dysmorphia, body hate, and generally feeling "fat" came back. It got me thinking to something my friend Charlotte said about her daughter. Maybe the "fat" feelings weren't really about fat at all. Maybe it was anxiety that she was trying to translate the best way she knew how. Given our culture's general angst around food and weight, maybe this is how we make sense of anxiety. It's got to be about food and weight, right? What other explanation can there be?

Obviously, this isn't the only explanation, but the more I think, the more I'm beginning to understand the validity of this. My stress today had zero to do with food or weight. Zilch. And yet I immediately started fretting about what I was eating and what I must weigh. Logically, I know my weight is probably the same as it was yesterday, and the day before that, and... I know that emails from editors don't magically make my thighs expand (seeing how many emails I get each day, that's probably a good thing). But that didn't stop my brain from diving into those old, familiar depths.

I don't think that this is the sole explanation for body dysmorphia in eating disorders--one of the emails today was from a piece about body dysmorphia that's will publish shortly--but I do think it explains why stress is such a trigger for so many of us. Our brains are just trying to make sense of something we can't explain, so we do the best we can with the vocabulary we have. My own vocabulary happens to be marinated in the larger culture of diet obsessions. Maybe Catherine of Siena would have worried about her abilities to be holy if she were in my shoes (and they had email and Whack-a-Mole in the Middle Ages). That might have been how she made sense of her compulsion to starve herself. I have the same compulsion, but a very different culture that provides a very different vocabulary.

It would have been nice--and much less patronizing--if instead of just saying "We know bad body image isn't about our bodies..." with an unavoidable patronizing undertone, my ex-therapist had said that sometimes our brains don't translate anxiety properly. That sometimes we get confused and attribute worries about something else to worries about food and weight.

This Wednesday, I had a chance to practice being spontaneous. A friend from my now twice-weekly knit/crochet group texted me saying "Feeling knitty? Wanna meet at XX Deli for dinner and yarn?"

Wednesday is, of course, my Zumba class. I had been planning to go and shake my thang. But this girl had come to our newest group up near my place the night before, so I thought I should probably return the favor and drive down to hear get-together. So I rode my bike instead of shaking my bootie, and went to the deli.

It was really fun, but let me tell you, it stressed me out to no end. I had to navigate changes to my eating and my exercise routines (oh, the horrors!) on the same day with basically no warning.

I got to the deli--I had never heard of the place before, but apparently it's some sort of a chain--and had another freakout. The menu was huge. I had no idea what to pick. To make things even more interesting, they had a "Light 'N Healthy!" menu. Not ordering the so-called "healthy" or low-cal, low-fat items still stirs tremendous guilt and anxiety. I mean, what are the people behind the counter going to think of me when I order something from a different section?!? If one section of the menu is "healthy," then the other is (presumably) not healthy. Or less healthful. Or whatever.

I was anxious to begin with, and then I had to figure out what to order and all of a sudden, I found myself at the front of the line. So I ordered off the "Light 'N Healthy!" menu. I was literally like a deer in the headlights. I froze. The one little section of the menu at least narrowed down my choices to something manageable. By the time I got the sandwich, the side, and the free frozen yogurt (free froyo? Why yes, I think I will), it was probably equivalent to a "normal" dinner. The sandwich was pretty good, all things considered.

I have mixed feelings about how the evening went. On the whole, it was probably positive. I did something spontaneous. And social. I switched things up. The anxiety, however, was a pretty big sticking point. I know I shouldn't have ordered off the diet menu. That the decision (to go to the event, or what to order off the menu) shouldn't have sent me into panic mode.

I hate that things like this are still so stinking hard. I'm doing better, so much better, in a lot of ways. But having to make snap decisions and do things outside the norm still cause ridiculous amounts of anxiety.

This past September, I upgraded my Blackberry to an Android. I love my new phone. The one problem I have is that the battery loses juice really quickly. I Googled the problem, and I found some apps that can shut down the other apps not in use that are slowing down the processor and sucking the battery dry.

{{In fact, my phone just eeped at me that it needs to be plugged in.}}

I was aware, of course, that apps run even when you're not actually using them, but I didn't know how much power they sucked up. On days when I'm not using my phone a lot--it's rare, but it happens!--the apps running in the background don't really pose much of a problem. I just plug in my phone before I go to bed like usual and all is well. Most days, however, I use my phone for pretty much everything, especially since I found a free Sudoku app, which keeps me entertained on my nightly Adventures in Insomnia.

I've been pretty busy with things lately, mostly work and writing stuff. I'm chugging along on my book, I've been freelancing, I've been crocheting, doing the recovery stuff. If I were my phone, I would be in a period of almost constant usage. It makes the ED stuff painfully obvious because there's not much energy leftover.

The danger zone for me is when I'm bored or work is slower. It's when the ED stuff isn't as obvious. The background apps suck the same amount of energy regardless, but it's harder to recognize all the time and energy it's using. The same for the eating disorder. Thoughts and behaviors suck up the same amount of effort whether I'm busy or not. I'm better able to recognize and fight them when I know there's lots of stuff on the line because I know I don't have that extra energy to spare.

Too much spare time isn't my friend. My brain is always working, always thinking. If I'm not thinking about nerdy stuff or yarn stuff or other stuff, then my brain will find other things to think about. Things like food, weight, calories, and exercise. It's hard to balance, since being too busy ratchets up the stress level to the point where I find myself reaching for the volume knob that is the eating disorder to turn down some of the stress.

Like so many things in recovery, it's a balancing act.  But this knowledge is helpful--I know that letting myself get too bored is just as bad as getting too busy. For now, being busy is good for my recovery. Not to distract me from anxiety, depression, and all of that other crap, but to make it painfully obvious just how much the ED takes out of me.

I am once again on the road for my freelance job (meeting to go to this morning- I left my place last night, spent the night in a nice hotel with crap Internet access), which means facing the task of eating on the road. I knew that I would need to eat dinner at about the halfway point of my 4.5 hour drive, seeing as I left at 5pm. I had found a craft store to pick up some yarn at the halfway point (I feel ridiculously oblique writing this, but I'm really paranoid about privacy since I use my real name), seeing as the store by me was all out of the one color that I needed, so I figured I would eat after I got my yarn.

Which I did.

I was going to go to Panera, since it's a pretty "safe" choice AND one where I know I could meet my meal plan requirements without flipping out. But en route from the craft store to Panera, I saw the sign that Moe's Southwestern Grille had recently opened. We have a Moe's by me, and it's a favorite of mine and my parents.

I have my "usual" that I get when I go. It started as a way to use a coupon or some other deal, and I really liked it, so I kept ordering it.  It's pretty much my default when I go. I don't go to Panera that much, so I didn't have a default decision.

The more I thought about it, the more I realized that one of the reasons I really wanted to go to Moe's was because there was a default. I didn't have to decide and calculate calories and things like that. I could just order and pretend I was sort of human instead of agonizing over the menu for half an hour and then spend the next little bit filled with gut-gnawing doubt that I had ordered the "right" thing.

It's hard to explain to someone who doesn't have an eating disorder, exactly how hard restaurants and ordering can be. I don't really have food fears anymore. I'm a little wary at the idea that I don't always know exactly what's in my food, but generally I'm over that. I can deal with it just fine, even if it isn't my favorite idea. For me, the anxiety is over having to decide what to eat from a vast array of options. I find it totally overwhelming.

So that's why I wanted to head to Moe's with my "usual."

Don't get me wrong- I loved my dinner and am glad I ate there over Panera, all other things being equal. But it made my life so much easier to just order without looking at the menu and second-guessing myself. I am that much of a creature of habit. I didn't even think to order anything else. And it was nice to be on my own and eat a complete restaurant meal by myself and not have a total breakdown.

Maybe that's part of the function of "safe foods." It's not just that they're generally lower calorie or whatever, it's also that they help limit our choices when things get overwhelming. Options are a good thing--really, they are--and I'm definitely glad that I've tackled my fear foods. But it also helps for me to have something to order when I can't make up my mind, too. That I can default to XYZ and meet my nutritional needs and also find a pressure release valve for my anxiety.

Does that make any sense? Do any of you do this, too? Please share in the comments, but also try to be mindful not to be too specific about foods and calories lest things get competitive or triggering. I want my blog to be a safe place!

Between my stressful week at work and then food poisoning, my weight has dropped some. I suppose I wasn't that shocked to hear it- even with just the illness, my eating hadn't been optimal for several days. I was, however, a little startled at how much (my therapist was rather cryptic, saying "more than a few." I have my guess at what that means, but still).

I suppose I could launch into a rehash of the potential reasons why. I could have pushed myself to try and eat more while sick. I could have been more careful while at my work conference. Coulda, woulda, shoulda. I'm not trying to wash my hands of my responsibility in what happened, nor am I trying to take on responsibility where none existed (though I am kicking myself for eating that damn hot dog that most likely got me sick).

I tried adding a little bit more to my normal meal plan, but that didn't do much. In fact, my weight dropped slightly more because my metabolism kicked in again. This led to a very frank discussion about What I Was Going To Do About This.

The difference--the massive, can't-be-overstated difference--was that I was able to fully participate in this discussion and follow through with what I promised. I don't like much of what I'm doing- Ensure Plus can go suck it, thank you very much. Ditto for the extra snack. Again, that's not the point.

I don't need to want to do this. I do, however, need to be willing.

Frankly, I do think my therapist is being just a tad alarmist about a single-digit weight loss. I didn't feel that I had lost weight. I'm not keen on going back to the chugging of the Ensure and the metabolic shift that once again leaves me burning through massive calories just watching TV.

But I could see it as necessary. I know enough that every relapse starts with "just a little" weight loss, however inadvertent (or, well, not) it might be. I know that good intentions don't save you. I know that promising to eat more is a long way from actually eating more. I know that recovery can be really f*cking inconvenient and you still have to do it anyway because an eating disorder is even more f*cking inconvenient.

So in the past few days, I have been eating foods I haven't touched for years: hot chocolate, Pop Tarts (not exactly a nutritional powerhouse, but sometimes it really is just about the calories), chips. It wasn't as bad as I thought. It helps that I know my metabolism is fierce at the moment and can "handle" the extra/sloppy intake. We'll see whether my weight changes this week. If it doesn't, well, we'll deal with that, too.

One of the most annoying parts of regaining lost pounds (even just a few!) is the hypermetabolism and accompanying hot flashes. I feel like a woman in menopause.

I've come to find the hot flashes appear on a regular schedule.  I eat, and then...wait for it...wait for it...I suddenly want to find an ice bath.  They only come after eating, usually within 15 or 20 minutes.  My therapist tells me it's a good sign, that my body is frantically burning up all of the calories (errr, nutrition) to repair itself. Personally, I just think it's the weight gluing itself to my ass really, really fast.

Which might be true, but it's annoying and frustrating to deal with several times a day.  I wish it would just stop.

And I'm kicking myself because I should have known better than to let the ED back in, even just a bit.  That I shouldn't have been this stupid.

I know that hot flashes will eventually pass.  That my body will adjust.  That (gulp) the pounds will go on, and the return to homeostasis is one of the benefits to weight gain/health/whatever positive spin you want to put on it.

I was reading one of Grey Thinking's posts from around Memorial Day (you don't want to see the number of unread items that are in my Google Reader right now), and she said this:

I think this is a huge roadblock for many people in recovery — having a lot of insight and knowing what they need to do, but not being able to do it and make changes (or not really wanting to).

It was certainly a massive roadblock for me.  Insight into the "whys" of an eating disorder was seen as my ticket out of my disorder.  Maybe if I uncovered the family dysfunction.  Or the ways in which I felt out of control.  Or could understand why I felt the need to be thin. My insight into insight is this: it's a little a lot overrated.

I knew I was a perfectionist and a control freak--in fact, I frequently thought I wasn't good enough to be considered a legitimate example of either of them.  And there was family stuff, sure.  Who doesn't have family stuff?  I'd always had body dysmorphia.  I didn't know it was body dysmorphia, of course, but there was that, too. Insight really wasn't my problem.  Many of the young adults I met in treatment had some amount of insight--and yet there they were, back in treatment.  Just like me. 

I'm not convinced that having insight into what caused your eating disorder will get you well. But insight is still important to recovery.

So what in the hell do I mean by that?

An eating disorder is hard to understand while you're actually in it.  It seems obvious and sensible at the time, but when you look back, you sort of scratch your head.  So having insight into why you're acting so weird only works if you know you're acting weird. As well, the strength of the insight that promotes change has to be greater than the anxiety (or whatever awful feeling you happen to experience) that will happen as a result of that change.  Let me tell you--insight is very vague and ephemeral. Anxiety provokes action. Anxiety wins every time.

For me, insight into my illness's origins hasn't been the most useful thing to get me on the road to recovery.  As for keeping me on the road to recovery, that's a different story.

Here's the thing: insight comes in many different flavors.  Thus far, I've talked about the "why" flavor--why did I get sick, what caused this, etc.  The insight that has been useful to me is of the "now what" flavor--what I need to do in order to stay well, what my triggers and weaknesses are, what to do if/when I start to struggle.  It's still insight, but it's a different variety, and I use it totally differently.

For one thing, this type of insight is being used by a brain that is at least on its way back to normal functioning.  For another, there's not quite the uphill battle.  It's more of a let's-keep-this-rock-from-rolling-back-downhill kind of effort.  Okay, yes, you're still fighting gravity, but at least you don't have to get the boulder moving.

To take a line from Forest Gump, insight is as insight does.  To take Grey Thinking's tagline, "Becoming aware of your crap and actually overcoming your crap are two different things."

For much of the past few weeks, my long hours working were because I was desperately in search of a story assignment.  This past week, I actually had said story assignments and now I'm busy completing those stories and sending out feelers for future stories.

Same long hours, only I'm actually getting paid.

I feel this is a good thing.

The real benefit (besides the paycheck, that is) is that all of this work keeps me somewhat distracted from the fact that I feel like a cargo ship.  Even when I can't forget about my ocean liner status, my work reminds me that I can still be a successful person even if I put on weight, or even if I'm not exercising and eating heaps more than the average person.

My work gives me a sense of purpose that not much else does.  I like what I do, and I find it more rewarding (long-term) than the eating disorder. Not letting myself get too sick to work is a huge motivator for me.  The drive I had for all those years to lose the most weight is still there.  I'm just trying to reign it in a bit and redirect it into something more positive.

Of course, this drive still has many of the same pitfalls as when I was anorexic.  I never feel good enough.  I always feel the need to be doing more.  I worry that I won't be successful.  I have that constant refrain in my head: "I suck, I suck, I suck."  It's very easy to throw myself into my career to avoid these anxiety-provoking thoughts in the same way I did with the eating disorder.  I realize I can very well transfer one bad "habit" for another.

It is a risk.  On the other hand, when I can quiet the cacophony in my head, I also find my work engaging and fun.  I am driven to write well, but I rarely feel driven to write, period.  That's something I want to do. 

My career won't cure my eating disorder, but staying busy with, well, life is a big help.

Thank you all for your kind and wonderful comments on yesterday's post.  They were really helpful for me.

What I've come to realize over thinking about this awful fatigue and hypermetabolism mess is that I need to practice some serious radical acceptance.  Not that I expect that this will eliminate my fatigue, but hopefully, I can scrape up a few scraps of energy that I was wasting on resisting and fighting the current state of events.

So what do I need to accept?  Several things:

1. My need to eat a lot. My mom tells me most people would kill for my metabolism.  I tell her they don't need to bother, as I'm perfectly happy to give it away upon request.  But there's not much I can do about how much food I'm burning off right now.  It's just reality.  It's what I need to do to get better, it sucks, but there's also no real alternative.
2. I'm not going to be as productive as I usually am. This one is really hard for me. I generally hate on myself if I'm not constantly busy. It's fine when I have the energy, am engaged in life, and can plan in some breaks.  That's not my current life.  Again, it's unavoidable.  I'm lucky in that my work schedule is pretty flexible, and a couple of short months financially aren't going to be the end of the world.

I still don't feel good about these things, but I feel a smidge better. 

It's hard for me to just "accept" something.  I generally try to fight it, or change it, or subvert the system if there's something I don't like.  I'm not naturally very zen.  I'm anxious and high-strung, I don't like to just "be," and I don't generally take things in stride.  So radical acceptance is a very new concept for me.  New, but helpful.

What's something you're looking to radically accept? Share in the comments section!

As I have promised, I'm going to do a few posts on some of the things I learned while at the AED conference last weekend.

The best session I went to was called "Who's Who in the Brain?" and it looked at what neural systems malfunction in anorexia.  To try and summarize the talk would be ludicrous, especially since the best part was interactive.  Basically, session leaders Bryan Lask and Ken Nunn had us get into groups of 8 (since most of the participants were MDs or PhDs, there was a little bit of eye rolling at this suggestion) and we each took on a role of one of the neural systems profiled, from the nucleus accumbens (the pleasure center) to the prefrontal cortex (PFC, the "executive" or decision-making part of the brain).

We were given the task of trying to decide where to meet for dinner.  We each had to play the part of the brain part we were assigned (I was the basal ganglia, which is involved in movement/exercise, precision, and also malfunctions during OCD. I'm pretty tight with my basal ganglia...) in deciding where to meet for dinner.  As the basal ganglia, I needed to know exactly where and when to meet, like give me some GPS coordinates, people, and exactly how much money did we have to spend?  So perhaps a little neurotic, but I was bound and determined to get us there on time.

The other five group members also provided their feedback, and the insula carried all of our messages to the prefrontal cortex, who made the final decision.  We were going to meet at the hip Asian joint down the street at 6:45 pm for drinks and sushi. Ta-da! Decision made.

Then, we had to make the same decision in a malfunctioning anorexic brain.  As the basal ganglia, I couldn't find the "perfect" restaurant or the "perfect" entree or be sure that everyone else in the group would agree.  The prefontal cortex was also malfunctioning, and pretty much left the five brain parts to rule in anarchy.  The insula was simply missing in action and none of the brain parts could talk to anyone else.

Our decision?

Skip dinner.  All around the room, the groups returned with the same verdict: no dinner.  With a malfunctioning brain, the decision was just too complicated, and so the "brains" defaulted on not eating.

Our group decided we'd get tattoos instead (there was some sort of inside joke there--it was tremendously funny at the time, but I can't exactly remember why). Another group went to the gym.  Mostly, people retreated to their rooms and spent a socially isolated evening on their own.

Sound familiar?

Lask and Nunn referred to this conundrum--an endless shouting by the various parts of the brain while the prefrontal cortex merely shrugged its shoulders and the insula had long since left the building--as analysis paralysis.  Wikipedia defines it as:

over-analyzing (or over-thinking) a situation, so that a decision or action is never taken, in effect paralyzing the outcome. A decision can be treated as over-complicated, with too many detailed options, so that a choice is never made, rather than try something and change if a major problem arises. A person might be seeking the optimal or "perfect" solution upfront, and fear making any decision which could lead to erroneous results, when on the way to a better solution.

Figuring out where to go for dinner seems like a pretty simple decision.  It's not like figuring out where to move or whether to take that job or how much to invest in your 401(k).  It's just dinner.  Yet the decision making process, though it can happen lightning fast, is also very complicated.  If the brain can't share and process information--if the insula isn't working properly--the brain gets stuck on the simplest of decisions, like a scratched record or CD.

The insula is known to malfunction in anorexia.  Starvation reduces blood flow to the brain, which makes other areas of the brain malfunction as well.  Soon, the simplest questions cause paralysis and the brain defaults to a simple answer: no.  I already ate. I'm not hungry. I'm busy. No thanks. I'd rather not. No. No. No.

It's our way of avoiding analysis paralysis.  Our brains, Nunn said, are rather like Congress.  Lots of bickering, lots of going back and forth, and without strong leadership, nothing gets done. Actually, even with strong leadership, things don't always get done in Congress, but I digress.  Even if the insula alone isn't working properly, the entire brain is affected, and it gets stuck in analysis paralysis.

The solution is for other people to step in and act as the insula and prefrontal cortex of the person suffering from anorexia, whether it's parents, caregivers, friends, or therapists.  It's often too complicated to decide what to eat, and so it helps for someone else to do a bit of the decision making, sometimes in the form of making all food choices, or giving guidelines in others.  Eventually, the brain regains enough function to begin to take over those decisions, and being able to easily make decisions is a sign of recovery.

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

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

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

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

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

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

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

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

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

I'll be honest: the past few weeks have been rough, ED-wise.  Nothing catastrophic has happened (as in, people are talking in nervous whispers about "hospitalizations" and such), but my weight is down some and I've noticed an uptick in ED thoughts and behaviors.  I've been remanded to daily doses of Ensure Plus, which isn't my idea of a good time, as well as upping the food intake.

As a consequence, I've been unusually tired and wiped out, which probably explains the decrease in blog posts over the past few weeks.  Either I didn't know what to say, or I didn't have the energy with which to say it.

The fight for recovery is exhausting, and I just want the fight to end.  I want food to be food and not filled with doubts and terrors.  I want my own mind to cease being a minefield and my own worst enemy.  I want anxiety to stop snowballing into something bigger and more sinister.

It's frustrating mostly because I thought I was past the point where I thought something this serious could happen.  I knew that small slips and things were likely just because life is life.  But to have to go back to Ensure Plus?  Seriously?!?

Ouch.  It's a bit of an ego blow, I'll confess.

The good news is that I've learned from previous experience and I'm not in any medical danger, I'm still working to my usual capacity, and I'm not a suicidal basketcase.  I've gotten a handle (or at least started to address things) before they spiraled totally out of control and I lost my ability to fight the anorexia as an outpatient.  Because as bad of an ego blow as this is, it's not as bad as having to quit my job and/or move home and/or go back into treatment.

So.  That's where I'm at.  Down but not out.  I'm pulling myself together and getting back on the recovery bandwagon.

I have been following an email discussion between eating disorder professionals, and the issue came up when Therapist A referred to those with anorexia as having an "unusual ability" to go without eating.  Therapist B said that this is more of a disability than a skill; people with AN are afraid to eat, not unusually skilled at starving themselves.

Therapist B has a point.  A lot of how people think of anorexia in popular culture (besides fetishizing thinness, which is another story) is that people with anorexia are, like, super skilled at not eating.  It explains why people have told me they wished they could have "a little" anorexia, or asked me for diet tips.  We can learn skills from others.  We can spend time with talented people and hope that it rubs off.  We can study with the best teachers and practice and...

Food restriction is a behavior.  That's just a fact.  But is it a skill or ability?

There's definitely a biological component to this "skill," but research has shown similar things for musicians and athletes.  That doesn't mean that Mozart wasn't talented because of some genetic blessings.

Where things get muddled is this: so many people engage in deliberate food restriction on a daily basis. I'm not talking about people with food allergies (though this is true for them), but about all the people who are dieting or trying to lose weight.  From the outside, a strict diet looks an awful lot like anorexia.  In western cultures, people with eating disorders and dieters often use similar terms to describe their thoughts and feelings about food and weight.

Some people are really good at dieting.  Others aren't.  I would hazard a guess that someone with anorexia would be really good at dieting.

But anorexia isn't a diet.  It can look like a diet, but it fundamentally isn't.  It's like saying that someone who is manic is really good at being energetic or that someone with OCD is really good at cleaning the house.  They might be, but it's not because of some sort of inherent skill.  It's part of the illness.

Often, when an eating disorder starts, it does appear that sufferers have an improved ability to restrict their diet (for whatever reason).  They can override hunger cues.  But as time goes on...as the illness deepens...that skill doesn't go away, but it ceases to be the main reason or motivation for ongoing food restriction.  That "natural skill" morphs into an illness.

What do you think? Share your thoughts in the comments.

Between the move and everything else that is going on in my life, I feel like I am juggling about 10 million balls, trying desperately to keep them all up in the air at the same time.  And I suppose not just keep them up in the air but keep track of where each ball is at any point in time.

If this were actual juggling instead of metaphorical, I'd be screwed.  My coordination is essentially nil.

Despite the metaphorical nature of my juggling, it is nonetheless exhausting.  I want to blog many nights, but I'm either too tired to actually put my thoughts into coherent sentences or too tired even to form thoughts, period.  I think back to my college days, when I lived on four hours of sleep and turbo-charged black coffee.  I was miserable and depressed, but I can't help but get jealous at the old Carrie who got so much done.  And then I feel lazy in comparison.

Considering I was neither mentally healthy (the OCD rituals were much of what kept me awake when I wanted to drop) nor do I really miss being that 18, 19, 20-year-old Carrie, I don't know why I haul out that old yardstick.  But I do.

One of the many topics I've been working on in therapy, from the first time I ever saw a psychologist over 10 years ago now, is "being gentle with myself."  Basically, it means sleeping when I'm tired, eating when I'm hungry, and so on.  As much as I know that not pushing myself to write in the wee hours of the morning is a victory, I still feel insanely guilty when I do lay my head upon my pillow.  As if the Forces of Lazy have somehow won a massive victory.

The years of abuse from the anorexia combined with the inexorable forces of aging have played no small role. My body simply won't let me push it that hard.  It falls asleep standing up.  It finds a way to sneak in a nap.

I took a power nap for about 30 minutes this afternoon, and I know I should be popping the champagne or something, but it makes me feel squeamish and guilty.  Sort of like when I eat something and it's not actually meal or snacktime.  My body doesn't follow a clock exactly, blah blah blah.  Logically, I get it.  But emotionally?  It's a whole different story.

I think it comes down to one word: should.  I shouldn't be hungry, I shouldn't be tired.  I have these internal rules about "appropriate" times to eat and sleep.  Feeling hungry or tired at "inappropriate" times really messes with my head.  I do love traveling, but the experience is often jarring for the first day or two, largely because my body clock is often thrown out of whack.  I do well with schedules.  I can become way the hell too attached to these schedules, yes.  But I also need them, probably more than most people.  Free time scares the hell out of me because I have no idea what I should be doing.  I've gotten okay with "me" time--reading, watching TV, crocheting, farting around in the kitchen.  All of these are fine.  But a block of time that I don't know what to do with?  Total freak out.

So I'm blogging about how I'm so damn tired I can't seem to work up the energy to blog, and here I've written a novel.  Figures.

I'm also falling asleep at the computer, so I'm going to call it a night.