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.

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

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

Basically, right on.

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

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

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

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

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

Ever since I got back from my super long bike trip (with the accompanying wrist injury), I haven't been able to ride. Basically, until the nerve heals, riding is a no-no. I tried my best to reason my way around that, but I couldn't--at least not without becoming really disordered or risking permanent hand injury. Seeing as I need to type to pay the bills, and crochet is one of my favorite hobbies, permanent injury would be really bad.

So no biking.

It's not been easy. Okay, yes, I miss the exercise part. A LOT.  I can do other things, but (insert whiny voice here) it's not the same. I've been doing an extra drop-in dance class at the community center to get some other type of activity in that doesn't involve my using my hands much. And I can go outside for a walk and do other things.

Really, though? I just want my bike back.

As hard as it is, the enforced rest from cycling has helped me better connect with what I actually like about the sport, above and beyond the endorphin rush. I like the wind in my face and hair. It's limited with a helmet, but still. I love being outside. I love being able to move under my own momentum. I like the solitude of being out by myself and deadline stress melt away because I can't do a damn thing about it when I'm X miles away from my computer. I also like feeling part of a larger community, even if they go much faster than me and are typically outfitted entirely in Spandex, which will never happen here, kids.


I also really like the feeling of achievement after finishing a long ride or improving my time. I try not to get caught up in the numbers and other minutiae, but it does feel really good when I beat times measured loosely on my iPod clock.

These feelings are very different compared to when I thought of exercise in terms of machines, blinking red numbers, and in quantitative categories of calories burned, miles run, and time elapsed.  It's less about "exercising" and more about the experience of cycling. No, thoughts of burning calories aren't really that far from my mind, but it's also not always my primary motivation for going. It's hard being deprived of one of my favorite healthy coping skills, but I'm surviving. I'm cranky and crotchety, but surviving.

I cannot wait, however, to regain strength in my hand so that I can get back out there. Only this time, I will wear my padded gloves the entire damn time, no matter how hot it gets.

I don't know how many of you are aware of my predilection for yarn, but crochet and reading are my two favorite hobbies. It's where most of my spending money is, well, spent.
I learned how to crochet when I was in treatment from a friend. My aunt had taught me the basics of knitting when I was 13 (I was in choir, and we got "picked" to be chorus members in the school musical production of A Tale of Two Cities. I was a French peasant who walked around knitting...with bright orange acrylic yarn, which I'm sure set the scene nicely), and I made the cliched scarf or four while I was in treatment. But I couldn't really get beyond the basic knit stitch.

Along comes my friend who teaches me to crochet, and it's something I really got the hang of pretty quickly. I didn't really look back after that. I even teach crochet on occasion.

A few of the things I've made recently:

Aria says "This is my blanky..."

In which the cat discovers my yarn stash

Leaf scarf

Crocodile stitch scarf

Chain link placemats

I could wax poetic on what crochet means to me, but I won't. I love the creativity bit, I love being able to transform a ball of yarn into a scarf or cardigan or blanket. I also love how relaxing it is for me. My fingers and hands are kind of hypnotized by the repetitive wrapping of yarn around hook. It's soothing.

On her PsychCentral post about the Zen of Knitting, Sandy Naiman writes:

It focuses me. My mind is often all over the stratosphere. My psychologist wanted me to learn to be more mindful, but I confess, I’m not into examining raisins. However, the gentle rhythm of knitting is perfect for me. The Zen of it works wonders for me.

The yarn tethers my wandering brain to the real world. It brings me back to reality. It slows my pounding heart and the silent whirl of racing thoughts.

I'm a writer. It's my job. For the past few days, I have been tasked with writing up a conference report I was at a week or two ago. The job was painful for several reasons. One, it was not going to qualify as life's most interesting writing project by any stretch of the imagination. For another, I really suck a summarizing things.
My lack of skills in this department weren't obvious to me until very recently. I didn't really think about it, nor did I really think about why the task was so difficult. It wasn't until I was researching an article on cognitive remediation therapy that I grasped the basis for my difficulties.

One of the tasks in CRT is to summarize a short story or a letter in just a sentence or two. The idea is to help people learn to understand the main idea of something rather than focusing on the details. At first, I thought this was a pretty unusual task- I mean, what could summarizing a fairy tale have to do with anything? But then I got to thinking: maybe this had more to do with anorexia than I previously thought.

Reading about this task reminded me of the time when my college roommate was watching me highlight my biochemistry textbook. I dutifully dragged my fluorescent green marker across lines of text, thinking I was marking up the most important sections of the chapter. My roommate looked over and asked why I bothered highlighting if I was just going to turn the whole page green.

"I skipped some words," I pointed out indigantly.

"True," she said. "I think you missed a 'the' up top."

In my biochemistry text, as in so many other areas of my life, I was so overwhelmed by the details of the information that I lost track of the entire point of highlighting. I only needed to highlight the key points, except I couldn't figure out what those key points actually were. I literally couldn't see the forest for the trees.

It was the same with my conference summary. The hardest part for me was deciding which aspects were important because it all felt important to me. Previous summaries I did when I was in school or at other jobs usually turned into long, rambling tomes because of this difficulty. Certainly, this "summary" wasn't short, not by any stretch of the imagination. But knowing what my difficulty was helped me focus my attention. I told myself that the actual writing bit was pretty straightforward, and so I needed to focus instead on identifying one or two key points from each presentation.

This wasn't easy. I worried a lot about missing something, and from picking one aspect over another. It's hard to move away from beating myself up over having trouble with what should be an easy task. But there's no reason summarizing "should" be easy. I finally finished the project this afternoon, and I am so, so glad it's over!

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.

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.

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!

I finally feel I have a moment to breathe.  I've been so busy the past few weeks that I really haven't gotten to just sit back and take a breath.  The upside is that I really do love my job, and so extra work isn't always a bad thing.  But I've been generally feeling stressed and utterly exhausted.  I usually wake up in the morning and feel ready to head right back to bed.

The ongoing insomnia isn't helping anything, either.

Still, I'm exhausted. 

I know I need to regroup for a bit, in order to face the next round of work, and the next round of recovery work.  I've written before that my work is a huge motivator for me in recovery.  For one, it gives my brain something to think about besides weight and calories.  And my identity is very tied up in what I do, so it gives me something positive with which to affiliate myself.

Because of this, and the fact that I work from home, makes it very easy to overwork myself.  Overwork isn't really any better than overexercise, and I'm psychologically and behaviorally prone to both. The other factor is financial--I had a couple of slow months earlier this year, and I can't afford more of that.  So I have anxiety driving me both to keep up financially and also to prove myself as a legitimate science writer.

I have plenty I need to do tomorrow, but I am also making a conscious effort not to overdo it.  To relax with TV show reruns in the evening and crochet, or read, or play with my cat.

So, yes.  Breathing.  Breathing is good.  I can't work if I burn out, and so working less now will let me do more later.

At least, that's what I'm telling myself.

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.

The past few weeks have been really chaotic, work-wise.  I actually haven't had that much work (I'm mostly finishing up old stuff), and so I'm scrambling to get stories placed so I can hopefully pay the bills.  Tonight, I got slammed both with a need to send out new ideas and finishing up a story from before.  When I figured out what my workload was going to be, I pretty much panicked.

How was I going to get all of this done?

I realized I was going to have to move some of my trawling for story ideas to tomorrow--deadlines always win out over no deadlines.  But I was behind anyway and frustrated, and then I had to contend with trying to schedule and then transcribe several last-minute interviews.  I was simply overwhelmed.

Photo by Summations

So I watched TV for an hour and did some crochet.  Then I went back to work.

I still have more to finish tomorrow morning, but that was part of my plan.  I feel okay now.  Still frustrated and disappointed at how hard it is writing-wise right now, but I put on my Big Girl Panties and did what needed to be done.  That "me" time was essential.  I wouldn't have made it through the rest of the evening without that little break.  But I did it.

I guess the moral of the story is that I can balance work and play, and that I can calm down and assess the situation like a professional.

I was in the bathroom today, and I got to thinking (thinking, for me, is generally a dangerous phenomenon and especially so when I have lots of time to myself, such as when using the loo).  Alcoholics can take Antabuse.  It doesn't take away the cravings or the ability to drink, it just makes drinking extremely unpleasant.  And I was thinking that it would be nice if I could have something like that for anorexia.  Something to make the illness immediately and acutely unpleasant.  Something to retrain my brain from thinking "But not eating will make me feel so much better..."

Of course, if an alcoholic really wanted to drink, they would just not take the Antabuse, but still.

I know that anorexia does make me feel worse in the long run.  But then I think that not eating will make me feel better right now, and it gets hard.  Because "long term" is very cognitive; "right now" is much more emotional.  It's much harder to use cognitive skills against a very visceral reaction.  It makes good evolutionary sense. When there's real danger, it's actually an asset to act without thinking.  The problem is that our brains generally suck at figuring out when it's real danger (as in OMG-I'm-going-to-be-eaten-by-a-tiger) and when it's not.  Again, thank natural selection.  It operates on whatever helps us survive and reproduce, not what makes our lives calm.

Which brings up the next question: maybe it's not my response (stress=ED thoughts), but my perception of danger.  The problem is that I find the world pretty terrifying.  And what do you do when you always feel on edge?  When you're never quite sure what will come back and bite you in the ass and so you treat everything like a rabid animal?

I think it's something I need to discuss with Dr. H tomorrow.  I know I need to desensitize myself to many of these things.  Exposure and response prevention is very effective with OCD, and I know personally that it's helped diminish my food fears.  But with the OCD and anorexia, I had something concrete to work on.  I was scared of germs.  Or food.  Or of hitting someone with my car.  Now, my problem isn't so much OCD but generalized anxiety, that constant "what if" chattering away in the back of my mind.

Anxiety can be overcome--or at least people can learn to live with it.  I'm still trying to figure out how.

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 was thinking about my snack this afternoon, and several options floated through my head.  As I was contemplating what to have, I remembered my after school snacks from almost 20 years ago now.

The fluffer nutter was one of my favorites. 

For those of you that aren't in the know, a fluffer nutter is a peanut butter and marshmallow fluff sandwich.  Except my mom didn't make fluffer nutters with bread. She made them with graham crackers.  Actually, I didn't know that my mom's confection had a formal name until I was in high school or college.  Nonetheless, I loved my peanut butter and marshmallow fluff on graham crackers.

Of course, an eating disorder changed that innocence where all I thought of was "sweet-salty-crunchy-yumminess." 

Now I think about things like carbs and whole grains and high fructose corn syrup.  I wonder whether I'm eating too much added sugars. I worry what others might think of a 30-year-old eating a fluffer nutter for a snack.  I worry what others might think of a 30-year-old having an afternoon snack, period.

The truth is this: I don't remember what it feels like not to worry about every crumb I eat.  I remember that there was a time when I didn't, but I don't actually remember that feeling.  Some of that loss may be the inexorable process of growing up.  After all, I think about lots of things in a much more nuanced way than I did as a 10-year-old.  But there's a difference between being aware of the fact that straight up sugar might not keep you satiated for long, and fretting over what the sugar might do to your butt.

I don't know that this innocence is ever coming back.  And that's sad.  I'm tired of worrying so much.  I want to switch this off, just for a bit.  Yet the fact of the matter remains that it likely won't every go away, not really.  Not completely. 

I'm not saying that this worry will never stop consuming much of my waking hours.  After all, I'm not dropping substantial cash on therapy for nothing.  I am working to relax about food and, you know, pretty much everything.  But I feel like I know too much and have let too much of my life be taken up by these obsessions to ever go back to the carefree person that existed before the anorexia struck over ten years ago now.

At the same time, I think it's important to remember that this person did exist in the first place.  That I could manage my food and weight without interfering in every little detail, without worry and fear and gnawing anxiety.  That I didn't need to follow a food plan to the letter and yet I was okay and the world was okay.  It's a very different mindset to how I currently manage things.

I suppose sitting here and being all mournful about these changes is neither uplifting nor enlightening.  I don't want to just piss and moan over what used to be.  I don't do nostalgia.  I can't change the fact that I got sick and have been sick and have changed.  It is what it is.  Time passes and the person I was has become the person I am now.

I'm not missing a sandwich, I'm missing a mindset.  But that doesn't mean I can't still enjoy a fluffer nutter or two.

When I don't want to deal with something--ED or otherwise--I tend to avoid it.  I must confess that it is, occasionally, effective.  Sometimes people need to let their tempers cool off, and sometimes rebooting the computer really does fix everything.

Most of the time, it doesn't end up like this.

Usually, the scenario goes something like this:

Make a small mistake.  Feel embarrassed.  Avoid dealing with small mistake.  Small mistake festers into a big mistake.  Avoid dealing with that, too.  And so it goes until I spiral into a masterly cycle of self-hatred and despair.  In the midst of this self-hatred and despair, I never really deal with the actual problem: my avoidance.  Instead, I tell myself that the real problem is that I'm lazy, stupid, and a bad person.

Aside from the verbal self-flagellation, the litany of reasons I suck gives me an out.  Bad people do bad things.  Ergo, I have no real reason to push myself to stop.

It happens with the ED stuff (embarrassment at a small slip -> don't tell treatment team -> I'm a failure -> small slip becomes a big slip), and it happens in real life.  I never really listened to criticism and helpful feedback because in my mind, anything less than perfect was just an example of how crap a person I am.  I didn't listen because there really wasn't much point.

So I avoided even more.  Pulled away, hid from view--even when admitting my difficulties would have made the situation so much simpler.

An example: I was late on a deadline this past weekend.  Part of it was the chaos of moving, yes, but once I realized I was overdue, I resisted buckling down and attacking my job.  Plainly, I was mortified at my mistake.  I can be a space cadet at times, but generally I can keep things put together.  By going back to my work, I would have to admit to myself that I wasn't perfect, that I had royally screwed up.  So I put it off.  It was the weekend, and it wouldn't have mattered much anyway.

There was an element of truth to that.  But if I was being honest with myself--
If I cut the bullshit and really admitted to myself what was going on--
I was avoiding dealing with the problem.

A simple email to my editor saying "Oops, totally forgot in the moving chaos, I'll get something to you by Monday morning," would have essentially fixed everything.  Sending that email would mean I had to admit something was wrong.

I didn't want that.

I wanted to pretend it was all okay.

That wasn't okay.

The ED was a way for me to avoid so much of the crap that was going on in my life.  I didn't actually have to deal with it because I was focused instead on exercise, food, and weight.  When I was into the anorexia, I mentally checked out of life.  I didn't intend for that to happen, not really, but it fit my profile of dealing with things.

Avoid.
Ignore.
Smile through the tears.

Neither my reluctance to send an email nor the anorexia-driven avoidance really ever solved any problems.  I could pretend for a while.  Pretend that everything was fine, that it was no big deal, that I could manage everything.

This weekend reminded me that I couldn't.  My editor asked me to kindly send her an email when I was going to be late.  To be honest, I earned that. 

But this screw up allowed me to see another of anorexia's accidental functions.  I could connect the dots and see the patterns.  Avoidance.  I started to see the consequences, for once.

So I stepped out of that self-hate spiral and told myself: the only way to solve this problem is to get to work.  Not punish yourself with more exercise or less food or some other misadventure. I didn't need punishing, I needed to sit down and finish what I had started.

And so I did.

On this past week's Sunday Smorgasbord, one of my readers asked me for hints on breaking free from that maelstrom of worries that so often overwhelms people with eating and/or anxiety disorders.  I'm not saying that I'm an expert on this, because I frequently find myself sucked in to my worries, which never results in anything productive.  Nonetheless, I'm getting better at surviving the worry storms, and here are some of the tricks that I use.

1. Breathe.  It's a classic.  Take a deep breath.  Or several.  Deep breathing is very calming in and of itself.  Besides just breathing, pay attention to your breath as it enters and leaves your body.  Feel your lungs expand.  Feel the tiny hairs on your upper lip ruffle as you exhale.  It's called mindfulness, and it helps bring me back to the present moment and the present problem.

2. Take a break.  It was one of my homework secrets in high school and college: I always started the frustrating work first.  Not just to get it out of the way, but also so that I could take a break and work on something else if and when I got too anxious and frustrated.  Often, walking away from my physics or linear algebra homework, doing something else, and coming back to it after I had calmed down and regrouped made things go so much smoother.  So if balancing your checkbook is causing you to freak out, put the calculator down, do something else, and come back to it.  You will think more clearly and find the task much easier to accomplish.

3. Prepare for the worst.  Yeah, I know, much of The Advice out there is to tell ourselves that our worries are exaggerated and look at them rationally.  Which is a good thing, but often I find it more helpful to just bite the bullet and prepare for the worst.  If the ultimate worry is that I'm going to go broke and end up on the streets, figure out a plan.  What savings do I have?  What resources can I call upon?  What are my other options job-wise?  I don't spend a lot of time on this, but just knowing that even if the worst does happen, I can handle it calms me right down.

4. Animal therapy.  My cat or another furry friend always makes me feel better immediately.  It's like I can exhale just a bit.  Besides, how can a soft, purring kitty not make someone feel better?

5. Distract yourself.  This is a little different from #2, although it can be used as part of the "do something else."  Sometimes what I need isn't another task because I'm too frantic to concentrate.  I need something more distracting and mindless.  For me, watching re-runs of TV shows (I love House) or movies is calming.  They're familiar, as I've probably seen them before, which is soothing in and of itself.  And they get my mind off of whatever I'm worrying about.

6. Talk about it.  This is not something I'm good at.  I hate talking about my worries because what's the point?  Often, no one can help me, and I feel like a burden--or at least a neurotic basketcase.  But even if someone can't do anything about what's got my panties in a knot, just saying it out loud helps.  And many times, my friends and family will have a different way of viewing what's going on that can help, too.

7. Better living through chemistry.  I have a prescription for lorazepam (Ativan) for when I'm freaking out, panicky, and nothing else has worked.  Or I'm so wound up that using a coping skill is just ludicrous.  I resisted for a long time because I was afraid that benzodiazepenes were addictive, and I didn't want to just pop a pill.  But even just knowing that I have the pills in reserve helps me get through bad situations because I know I have something to make it better.

I've read a number of studies that show people with eating disorders have difficulty reading emotions in other people.  A new one came out this week. The general theme for people with anorexia is that they tend to be hypersensitive to anger--that is, they see people as angry, even when they're not.  No one really seems to know why this is, but it seems to be one of those general traits of people with EDs.

It's something I know a lot about.

I don't like social situations for any number of reasons (anxiety, etc), but I also tend to dislike them because I always feel that everyone hates me.  Saying that they hate me is probably an overstatement, but I am usually very uncertain about how people feel about me.  My brain tends to hone in on even the slightest hint of anger or ambivalence.  I can never quite seem to tell what people think of me.  On the one hand, my brain sees lots of anger.  On the other hand, I often don't see much angry behavior directed towards me.  Or at least not a huge amount of it.

So yeah, social situations are very confusing and difficult for me. 

It's not just random social situations, either.  I've often thought my mom was angry at me or yelling at me when she wasn't.  She might be stressed, even if it's unrelated to me or the ED, but I interpret it as anger.  And when someone is mad at me, I feel that they must hate me. 

What this really means is that I feel I live in a hostile world.  It's scary, and it doesn't help with my stress level.  It helps to explain some of the reason I have lots of anxiety, and why I tend to isolate myself.  Meeting new people means wading through even more uncertainty and feelings that someone is angry with me.  Anorexia played into this by almost buffering me from these feelings.

I find reading these studies helpful because it helps me reframe social situations.  Instead of leaping to conclusions that, in fact, people really do hate me, I can remind myself to wait for something more concrete than random worries.  I can try to assess the situation before letting my emotions take over.  I still don't like social situations, but I'm getting better at dealing with them.

Now that I've closed on my house and am waiting to hear about several writing gigs in the near future, I'm sitting with a lot of anxiety.  Like many people, especially those with eating disorders, I find change difficult.  The thought of change makes me nervous and apprehensive--what if things don't go right?  What if they do?

Then there's the simple fact that I don't like change.  It's a fact.

Let's face it: I'm moving from an environment with a built-in support system to living on my own (albeit only fifteen minutes away).  I have some career uncertainty, and with that comes financial uncertainty.

In the past, I have tried to cope with change in some, shall we say, less-than-productive manners.  I have too much on the line now.  I don't want to go back to the eating disorder.  Which means I am going to have to figure out some way to cope with the change.

Basically everything in my new place will be familiar, as I already have most of what I need.  I'm having a new sofa delivered tomorrow, but that's pretty much it.  I will also have mostly the same food around, and use tried-and-true recipes.

Oh yeah--I'll also have the same cat. :)

In the past few months of freelancing full-time, I've come up with a solid daily routine. It can be a little unusual (I hate mornings and don't expect that to change), but it works for me.  So I have that to rely on, too.

What has helped me the most is reminding myself that I have the skills and strength to cope with these changes, even if they do go pear-shaped. That I've coped with it in the past and I can do so again.

Change does stir up a lot of ED crap.  The body dysmorphia has never really gone away, and the chattering has gotten a little louder recently.  I've started to fantasize about having my own exercise equipment--what fun I could have!  I know that's a Very Bad Idea, and even if I didn't, I don't have the spare change to buy it anyway.

I have to keep telling myself that these thoughts are just a sign that I am stressed, not a sign that I am a fat, lazy cow.  Having a thought doesn't make it true. {{See, TNT, I really was listening!}}

I also have to keep telling myself that it's normal to feel apprehensive at times like these.  When I was first diagnosed with anorexia, I was told that I was having trouble "individuating" from my parents.  Aside from the fact that, outside of my mental health issues, I was handling my own life just fine, thank you very much, didn't seem to matter.  I've been itching to start my own life for months now.  But with the privileges of adult life (you mean I don't have to go to bed on time?) come the responsibilities.  Paying the bills is a pain in the ass.  So is emptying the dishwasher and taking out the trash.  As much as I hate the fact that I'm currently living with my parents, I also know that I've had things pretty plush.

My goal for the transition is to establish healthy new routines so that I can stay sane and stay on track with my recovery.

Last night, I had a fat attack.  My old therapist back in Michigan would have preferred that I reframe it as a "bad body image attack."  Well, maybe.  But this feeling was very different than looking in the mirror and saying "Ewwww..."  Which I've also been known to do, but not last night.

For starters, I was laying in bed and not looking in the mirror.

For seconds, it wasn't a visual issue.  It was a more physical, visceral issue. 

I wanted to claw my way out of my own skin.  I felt huge, uncomfortable.  I couldn't stop thinking about my body.  I wanted to do something, anything to get rid of this feeling.

Somewhere through the anxiety, I started thinking, "You know what this reminds me of?"

OCD.

I had the stereotypical germ OCD when I was in high school.  Mostly, I obsessed and worried over every little thing.  Either I was harboring some nasty germ that was going to kill everyone I knew or saw or had contact with, or everyone I knew, saw, or had contact with had a germ that was going to kill me.  I would wash my hands or reply scenes in my mind to make sure I hadn't touched something "bad" or coughed wrong or whatever.  I would inspect every inch of my skin to make sure I didn't have any cuts that could get or receive germs.

Therapists call these contamination fears.

I felt like my skin was crawling with germs.  I washed my cracked, pathetic hands in bleach to try and make this feeling go away.  No, I couldn't see the germs. I wasn't always 100% positive they were there, but I was sure that I could feel them.  All I wanted to do was make that feeling go away.  If it meant screaming in pain from bleach, so be it.  I was so distressed and terrified that nothing else mattered but making this feeling go away.

Which brings me back to the fat attack.

I didn't feel that my skin was crawling with germs, but it did feel like it was crawling with fat cells.  And in moments like that, it suddenly doesn't seem so foreign/stupid/pointless to do something like purge or overexercise.  I didn't, but nonetheless.  Thinking of these fat attacks as another manifestation of my OCD has made a lot of sense to me.  Yes, I have significant body dysmorphia above and beyond the fat attacks. 

Yet any time off exercise or eating something "unsafe" or "forbidden" would bring about a fat attack--just as touching something dirty would set off a contamination attack.

I don't think this totally explains my eating disorder.  Not at all.  But it does explain parts of it.  It helps explain why I would do such crazy things.  To escape the distress.  To keep the calm.  Vanity and sticking to my "diet" wouldn't--couldn't--explain this.  If you're scared enough, you will do some crazy things.

I never was able to recover on my own as an outpatient because the fears and the feelings were just too strong.  It meant living in a non-stop fat attack for months with no sense of relief.  Considering the crazy stunts I pulled to avoid the feeling just for a few hours or days, is it really any wonder that I tried to avoid refeeding and recovery?

Seeing fat attacks as OCD helps me calm down in the moment.  It's just the OCD talking.  The OCD was wrong about me spreading or receiving the plague, so it's certainly wrong about this.  What's more, I know the awful feelings do pass.  Eventually.