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.

Yeah, I know. An illustrated guide to depression? Comic strips don't generally cover things like, you know, depression.

But Allie over at Hyperbole and a Half did.  It's probably the most accurate representation of what it's actually like to be so depressed you can't quite get out of bed.

Apparently, you don't need an advanced psychology degree to help people understand mental illness. All you need is a computer doodle program.

{{If you don't read her blog, you should. It's pretty much epic.}}

The last week or so has been one massive slog through writing, editing, revising, interviewing, and writing some more.  It is, in a sense, a very good sign that I'm rather swamped with stuff.  It tends to make paying the bills easier (although some of that writing is for a freelance gig that I'm "auditioning" for at this stage, and therefore no payment is guaranteed. But it's a great career opportunity, and I'm excited about it).  I have a headache, I can barely keep my eyes open, I want to beat my head against my desk in frustration half the time as I'm trying to write about science I can't quite wrap my mind around.

I'm simply exhausted.  I just want to nap.  I took an hour or two this afternoon to read, as I had a brief reprieve in the never ending gauntlet of deadlines.  But tonight it's back to the computer and work, followed by more of the same for tomorrow.

This kind of grim exhaustion, followed by the deep inner sense that I have a job to finish, reminds me of eating in the early days of recovery.  I would have gladly eaten all of my exchanges at an all-you-can-eat buffet first thing in the morning so I didn't have to worry about eating the rest of the day.  I was just so sick of the endless slog through meals and snacks.  I wanted it to go away.  And that's what this is kind of like, although I do actually like writing, which I couldn't say about food back then.  It's this numb exhaustion, combined with the knowledge that the end result is rewarding.

Today's work really hurt my brain, as I'm trying to write smartly on science I'm not exactly sure I understand.  In fact, I'm pretty sure I don't understand it one bit, and I had to eventually phone the researcher and ask him to explain his work using words with no more than three syllables.  I still don't think it worked.

And this exhaustion has led a slight uptick in feelings of depression.  It's more of the anhedonia and apathy caused by being too tired to care much rather than an actual "I hate my life" feeling.  I used to deal with this in a very ED way.  First of all, I better not be tired because I still had to get through my exercise routine, and I was never too tired for that.  The exercise also served as a little pick-me-up, and as a vent for my stress.  It's hard not to turn to that when I know it's so effective--at least for the short term.

I suppose this is part of what recovery and life are all about. Surviving the crappier times without resorting to unhealthy behaviors.  Recognizing that said crappy time won't last forever.  Integrating self-care into your life (such as my reading and blogging this afternoon).  And the acceptance that the ED won't change your current situation for the better.

I'll admit I moped a bit this morning (well, early afternoon. I didn't wake up until 11am). Then I mailed out a contract, talked to a researcher in Portugal, cringed at the thought of my phone bill with all of these international calls (three others last week), and sat down with a cup of coffee to watch a little TV mid-afternoon. I didn't have anything real pressing, and I was curious to see what was on.

I had just put my feet up when I get a text message from my boss at the bakery- she wants me to come in ASAP and help close. Since I didn't have anything better planned, I said okay. I could use the money and it seemed like a better idea than just trying to find something better to do. I put on my old baseball hat and name badge, and I go into work.

I don't miss the bakery, not really, and I still don't. But I think there is something therapeutic in mild physical labor, in having heaps to do and just bulling your way (mostly) through it. There was the connections with my coworkers as well, or even just being in someone else's company. Perhaps just as importantly, it got me out of my head. All of that.

I'm done with my shift and feeling much better. I do better when I have a lot to get done. I really enjoy feeling productive and checking things off my to do list. And it felt good to be really busy (though not the sweating buckets bit...that wasn't pleasant in the slightest) and now to be tired in the way that signifies you've really worked hard.

I know I work hard at my writing, but this is a different kind of hard work. It's given me a bit of insight into why I found exercise so addicting: it was this pseudo-productivity, the good tired of having exerted myself, along with the endorphins and semi-dissociation from what was bothering me, and the OCD ritual of it all. My brain sort of shut off when I was exercising, just as my brain powered down a bit during work. The moment became about the doing rather than the thinking.

Don't get me wrong. My back hurts and my feet hurt and I really stink at the moment. But about 6 hours at the bakery just flinging bread and packaging croissants and getting disgustingly sweaty really improved my mood and my outlook.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I hate winter. First off, I hate the cold. I've never liked it, and my eating disorder history only makes my cold intolerance worse. I'm also not fond of the ice, seeing as five years ago, I slipped and fell on a patch of black ice and shattered all of the bones in my osteoporosis-riddled ankle that All the Kings' Horses and All the Kings' Men had to put back together surgically.

But the part about winter that really gets me down is the darkness. My depression tends to get worse in the winter, and I've had several meltdowns around December and January. It happens with such remarkable precision that I have to wonder. I have the little lamp that I try and sit in front of, and I'm not sure it helps, but it doesn't hurt. (Maybe it works because Aria treats it like her own personal kitty-sized tanning salon and basks in the light while it's on, which is hilarious).

However, after reading that CBT is more effective for seasonal depression than light therapy, and getting tired of the constant dread of winter, I thought I would try to find things about winter that don't suck.

1. The cold makes coffee taste better.
2. More darkness means better effects from my candles.
3. Scarves!
4. Wool socks.
5. Looking out the windows at the pretty snow.

Can anyone add to my list? I'm not looking to make winter my favorite season, but it would be nice not to start getting sad in August when I realize that all of this lovely daylight is going away.

"The world has no room for cowards. We must all be ready somehow to toil, to suffer, to die. And yours is not the less noble because no drum beats before you when you go out into your daily battlefields, and no crowds shout about your coming when you return from your daily victory or defeat." --Robert Louis Stevenson

This is something I struggle with immensely: giving myself credit for what I do.

When I first started my job last fall--my first "real" job after grad school and the Big Fat Loser debacle--I had to wake up, every morning, get dressed, and get out the door on time. I've never been a morning person, but that wasn't exactly it. During my last job, I was walloped by depression so intensely that some days, getting out of bed didn't seem to be an option. I put my time in, yes, but at odd hours and in a less-than-functional way. But at this job, it was different. I had my occasional days of turning off the alarm in my sleep, but mostly I got up, I got dressed, got out the door and got to work on time.

So, like, yay me, right?

I scoffed at the idea of congratulating myself for this. I mean, I was valedictorian in high school and salutatorian in college. Clearly, ambition and drive were not things I struggled with, nor was depression a new thing for me. My high school and college years were a torrent of anxiety and depression, but a torrent that left me quite functional. Schoolwork served a similar function to the AN, which it allowed me to channel my energies into a number, and raising (or lowering) that number was a tangible bit of evidence that I could still do something, anything, just one thing, right. If I could go to class when all of this was going on, then why should I feel thrilled for being able to do what everyone else seems to be able to do effortlessly?

Well, I don't know the answer to that. I still don't. I am immensely uncomfortable with praise, seeing that the results were as much from luck or chance as anything that had to do with me. And praise for getting out of bed everyday? Well, halle-freaking-lujah! Even when I did feel momentarily proud that I was functioning like a normal human being, I never felt I could really share it with people. I certainly wasn't going to go tell my co-worker* that I managed to get up on time for five whole days in a row. They probably wouldn't get it, and then they would think I was completely whacked.

What helped was not only giving myself credit for getting up on time, but of letting go of my need for other people to give me credit. You see, I desperately wanted someone else to realize how big of a deal this was for me, but the words stuck in my throat. I was too terrified they would say, "So?" I wanted them not only to understand what a big deal this was for me, but also to understand how much effort it took just to do the simple things they probably didn't think about. Grocery shopping sans Xanax-popping meltdowns. Eating. Getting out of bed.

I've been working on letting go of my need for other people to really get it. I'm sure plenty of people do, but plenty of people don't. I don't need other people to appreciate the victories in really simple things for them to be victories. Would it be more fun that way? Probably. But I was there and am here now and there's this: I get it. I know the effort, the energy, the blood, sweat, tears, and spilled coffee. All of it.

I know the effort behind eating a tiny slice of bread from the bread basket a dinner time when my mom encouraged me, but didn't "make" me have some. A football stadium cheer might be nice for some of these events, but I'm also realizing that not having any notice at all is just as good. Because it shows that I'm returning to normal, that I'm slowly melding back in with the ebb and flow of life where alarm clocks ring and bread baskets arrive and no one really gives a damn.

(quote via Sharon)

*Which I wouldn't have for privacy reasons, even beyond the I'm-not-sure-you'll-get-what-I'm-talking-about part. I don't have co-workers as Facebook friends, and probably never will.

Many mental health conditions begin to emerge in adolescence. Some conditions, such as depression and anxiety, are much more common in adolescent females than males. For me, OCD emerged before any full-blown depression, although I did get very depressed during my OCD episodes. As the OCD improved, so would the depression. It wasn't until college that I was walloped with out-and-out depression completely separate from OCD.

But a recent study looking at how adolescents process emotions and social interaction shows how these features change during adolescence and how they can make a person vulnerable to anxiety and depression. The study asked a group of healthy adolescents between the ages of 9 and 17 to view a series of photos and determine both who they would be most interested in speaking with and who would be most interested in speaking with them. While they were evaluating the last question (who would be most interested in speaking with them), the teens' brains were scanned using functional Magnetic Resonance Imaging (fMRI).

During this evaluation, the fMRI scans found that older female adolescents showed greater activation in areas that processed social emotion, such as "the nucleus accumbens (reward and motivation), hypothalamus (hormonal activation), hippocampus (social memory) and insula (visceral/subjective feelings)." Very little shift in activity was found in younger vs. older male adolescents.

Lead researcher Daniel Pine, of the National Institutes of Mental Health, said this:

"In females, absence of activation in areas associated with mood and anxiety disorders, such as the amygdala, suggests that emotional responses to peers may be driven more by a brain network related to approach than to one related to fear and withdrawal," said Pine. "This reflects resilience to psychosocial stress among healthy female adolescents during this vulnerable period."

And it was this last quote that really stuck with me and made me think not just in terms of EDs, but in terms of ED vulnerabilities. Although I don't have social anxiety disorder, I do have social anxiety. Back in February, I had to go to a large science conference for work, and part of my task involved networking. My supervisor also went, and this is a man who loves to schmooze. He thrives on this kind of social interaction. I would just as soon volunteer to have a new dentist fix my messed-up teeth sans Novocain. I made my appearance, did my duty, and then got the hell out of there. I retreated back to my hotel room and read a book. When I have to mingle, I feel very anxious, very fearful, and more than just a little threatened. I'm edgy. I can't relax. I'm constantly evaluating how people respond to me and what they must be thinking and the second I can leave, I usually do.

So when Pine said that emotional responses in people with anxiety and depression are related to "fear and withdrawal," I realized how true this was. I'm guessing that I'm not the only person with an ED to respond this way to social interactions. This isn't true for all social interactions, but for many of them, especially where I might be "evaluated" by my peers. And maybe a transfer of activity from the more functional emotional circuitry (the nucleus accumbens, the insula, etc) to the amygdala is part of what drives not only the emergence of depression and anxiety, but also when these illnesses occur.

It seems odd that I, of all people, would have to remind myself of this. I can (and frequently do) go on hour-long diatribes about the real nature of eating disorders to anyone and everyone in earshot. It makes perfect sense that EDs in other people are mental illnesses because I can see the distortions. I understand how a nibble of a Saltine can seem like "too much food" or how running a marathon can be "too little exercise." I understand it and yet I can see that it's not exactly reality.

My problem is that when I'm thinking these things, they seem perfectly rational. If I had vowed not to eat lunch, and then had a nibble of a cracker, I would have griped about how much I ate. Because a nibble is more than nothing, I clearly ate too much. It doesn't seem distorted in the least. It seems normal and (dare I say it?) sensible.

This is where I have problems. I have a hard time understanding that MY distorted thoughts are symptoms of a mental illness.

I can compare my ED experiences with those I've had with depression and anxiety. I became inured to the mild depression and anxiety that characterized my life, to the point where I kind of stopped noticing it. But when I get really depressed or really anxious, I don't feel like me. I've never been high-energy, but when I don't even want to get out of bed, that doesn't seem like me. It's not pleasant. Taking a shower and going back to bed might be the actual best I can manage, but it's still not pleasant. When I first developed OCD in high school, I thought I was going crazy. I knew that my touch probably wouldn't cause someone to die of AIDS but I was so terrified it might that I washed my hands and tried not to leave the house if I could avoid it. I didn't know that this was , in fact, a mental illness called obsessive-compulsive disorder, but I was able to recognize that something was wrong. More than that, I was aware that other people knew that this was very bizarre behavior.

The anorexia was very, very different. Basically night and day different. Eating less and exercising more seemed very normal and rational and common. I got compliments about how "good" I was being. No one complimented my freakishly clean hands (thanks, Clorox and Ajax!) even though they were freshly scrubbed. No one complimented my ability to stay in bed all day or scream and cry and throw things at the drop of a hat. I had excuses for all of my odd ED behaviors. I had excuses for all of my other odd behaviors, too, but with the ED, I actually believed my own bullshit.

I seriously began to believe that a sip of water would make me fat, that I just "didn't like eating," that I worked better on an empty stomach, that I simply adored the treadmill. There were definitely OCD moments when I believed I was a death- and disease-spreading machine, but these moments also passed. The AN delusions didn't.

Although I continued to lose weight, I wasn't able to see it in the mirror. The number on the scale was different, my clothes were looser, but I still looked the same. Ergo, I must actually look the same. I could tell when other people had cut their hair or lost weight, so the same must be true for me, right? So if my mom is telling me I'm way too thin, I'm emaciated, I'm dying, and I can't see it, it must not be true. I mean, I know what I look like...don't I? I will eat, I told myself, when I see that I'm too thin. Oddly, this is the same trap I fell into on this latest relapse- I couldn't see a difference in how I looked in the mirror despite my almost hourly trips to the bathroom scale.

When I am really depressed or really OCD/anxious, I can tell a difference between those states and my "normal" state. When I am into the ED, it's much harder. I feel almost more like myself--more intense, more driven, more on top of things, in a sense, I feel like a better version of myself--when I slide back into the AN. I can't point to a difference. My mom can. My boss probably could. But if I feel the same and look the same and am just freaking fine, dammit then how in the HELL could I be sick?

How? Because the illness I have, this pernicious eating disorder of mine, makes it very very hard to understand that I am sick. It's one of the symptoms of the illness, this inability to understand that you are ill. Laura Collins introduced me to the term anosognosia and I love that word. Can't pronounce it, but I love using it. The depression and OCD aren't anosognostic- I knew damn well that something was up even if I didn't have a name for it and didn't know that it was a mental illness that could be treated. Anorexia is very anosognostic and it will probably be my Achilles' heel. Not so much the illness itself, but the difficulties in recognizing it.

However untalented I may be at recognizing my own eating disorder even when the evidence is literally staring me in the face, it doesn't change the fact that EDs are mental illnesses. Including my own.

In March of this year, I saw a new PCP for the first time in a while. I used the student health clinic while in grad school or have just continued seeing the same specialists (ie, psychiatrists). I told the doctor flat-out that I have epilepsy and osteopenia, that I struggled with anxiety and depression, and was in recovery from anorexia. We then did a standard family health history, in which I was asked about heart disease, cancer, and diabetes in my close relatives.

The PCP didn't ask about mental health issues in any family members, even though these were the main issues I was currently having (the epilepsy and osteopenia being, of course, secondary to anorexia). Even though, more importantly, that all three conditions (anxiety, mood, and eating disorders) have a substantial genetic component, and that a person is probably going to present to their PCP with one of these issues first, especially since I need a referral to see a specialist.

Recent research titled "Predictive Value of Family History on Severity of Illness" from the Archives of General Psychiatry examined how a family history of anxiety, depression, alcohol dependence, and drug dependence was related to age at onset, recurrence, impairment, and use of health services. The researchers found that family history was significantly associated with recurrence, impairment, and service use, though not age of onset, in each of these four disorders.

The authors conclude that "family history is useful for determining patients' clinical prognosis and for selecting cases for genetic studies."

So why have general clinicians shied away from asking directly about family history of brain diseases? They ask about Alzheimer's or brain cancer, but not depression and anxiety. Terrie Moffitt, one of the authors of the paper, gave two reasons in a recent press release. The first was the stigma attached to mental illness: even if doctors asked, would the patients respond honestly? Or would relatives even know about anxiety and depression in a close family member?

The second reason was related to the DSM itself, the Diagnostic and Statistical Manual of Mental Disorders, the so-called "Bible of Psychiatry," makes no mention of family history. At all. Whether this changes or not in the upcoming Fifth Edition has yet to be determined, but I think it's about time we simply started asking about mental health issues. Many risk factors are well-known, even if not well-understood. Even just by identifying those at highest risk, we can more quickly identify or even prevent some illnesses.

I know I write a lot on biology, and its importance in relation to eating disorders. Part of this is because I strongly believe in the importance of biology, and part of this is that I feel the cultural issues surrounding EDs get plenty of coverage already, so I tend to leave them alone.

But there was some interesting new research that looked at the relationship between negative mood, body image, and EDs in two different cultures. The authors compared groups of anorexic and healthy women from both France and Poland, and looked at how symptoms and duration of depression and anxiety affected both body image and eating disorder symptoms. Even considering that both groups of women were from Europe (though one from behind the Iron Curtain and one, well, not), the researchers still found differences between the two groups.

Both groups of anorexic women had higher anxiety and depression than healthy women, but the Polish anorexics had higher levels of depression than French anorexics. Depression in the anorexic Polish women increased both with age and Body Mass Index, but had no relationship to how long the women had been ill.

In the group of Polish women, high levels of anxiety corresponded to high levels of maturity fears and interoceptive awareness (i.e., the physical state of your body, like hunger, thirst, etc). In the French women, however, high levels of depression corresponded to higher levels of bulimia, ineffectiveness, interpersonal distrust, interoceptive awareness and maturity fears.

I'm not discounting the importance or relevance of the specific correlations the authors found, but that's not what I found really interesting. What this study says to me is that symptoms of anxiety and depression are important in the development of eating disorders no matter what culture you're from. But the details of this relationship can vary depending on your environment. Which just makes a whole lot of sense: people with EDs aren't (oh, the pun!) cookie-cutter people. Although there are remarkable similarities in people suffering from EDs, there are lots of differences, too.

When I saw my psychiatrist on Wednesday, she decided to raise my Prozac because I was feeling a smidge better but not all the way. I had been on a higher dosage before, and tolerated it just fine, so she thought that rather than prolong the misery, she should just try the higher dosage and see what happened. I took the first higher dose on Friday, and felt drained and dopey. Ditto for yesterday. I kept thinking "Must blog...must blog...must sleep..." and, suffice to say, sleep won.

Today, I woke up bright and early (for me, on the weekend)- thankfully I slept later than yesterday when Aria saw a bird right outside my window at 8:30am and just about went bonkers. She was hissing and "chirping" and running around the bed and...good morning, Your Royal Fuzziness. Thanks for the wake-up call. I spoke with my good friend IrishUp this morning as well, as we worked on a project for FEAST, and it was nice to hear her voice.

Then, as I was getting dressed and getting ready to make my weekly grocery run, it struck me: I felt strange. Like really strange. The weather is gorgeous out. Aria was acting freakishly cute. Though I wasn't looking forward to going grocery shopping, I wasn't exactly dreading it either. My body image isn't spectacular, but it's been worse.

I realized: could this be happy?
Could it?

When I was in residential treatment about 2.5 years ago (has it really been that long?), I remember when the other SSRI started to kind of work. I remember being utterly convinced that I was manic. That this chatty feeling, these giggles, were NOT NORMAL. It had to be pathological. I was not upbeat and talkative.

I explained these freakish symptoms to my therapist who looked at me and said: "Umm, honey, I think that's called happy."

Oh.

I guess it kind of drives home the point of how long I've been depressed, when having a good mood feels almost wrong. That it feels pathological, that I must be bipolar if I'm having a fraction of a happy thought.

But it isn't. It can be normal, just as ordering pizza can be normal. It's something I am hoping I will be getting used to.

It's only about 2 minutes, but it is a fantastic, easy to understand introduction on how to change your mind and change your brain.

Though the author just talks about depression, I think it applies very much to eating disorders.

The subject came up in my therapy session on Monday- was an eating disorder a coping mechanism or did it instead simply have an adaptive function? I've been mulling it over since then, following various thoughts to and fro, trying to put my finger on the exact difference between the two, and where an eating disorder really lay on that spectrum.

When I was first diagnosed in 2001, the basic mantra I was given was that anorexia was a "maladaptive coping mechanism" and that recovery meant I would need to learn better ways of coping than starving, purging, and exercising. This I understood--if I was to get better, I couldn't keep abusing my body so horribly and expect to live. But my understanding of anorexia-as-coping-skill got quite muddled when the rubber hit the road.

The sessions with my ex-therapist would go something like this: she would ask why I was restricting, I would say I don't know, I'm fat, it seemed like a good idea, I eat too much, etc. Then she would ask me to think about what happened that might have "triggered" this. Sometimes there would be a specific event, sometimes there wouldn't. But I never deliberately thought: gee, my life is stressful and anorexia would help me cope. Let's stop eating.

Yet I couldn't totally deny the fact that my eating disorder had a "purpose," as it were. I felt better when I wasn't eating. I just...did. It loosened the straitjacket of anxiety and depression that held me captive, only to entangle me in something far worse. Eating the same paltry food each day felt soothing, and the hunger pangs became confirmation that I was at least doing one think in my life right. When my depression got bad, I literally lived for the hope that tomorrow I would weigh less. That got me out of bed in the morning. The exercise and accompanying endorphin rush hit both anxiety and depression at once.

But I still wasn't coping with life, and I knew it. I was trying to seal the hole in the Titanic with bubblegum- a noble endeavor, perhaps, but entirely futile. The ship was sinking, I was aware of this, but at least the bubblegum made me feel like I was doing something.

I don't consider my eating disorder a coping mechanism any more, because I don't see it as a choice. A coping mechanism is something you choose. I fell into the eating disorder because of the way I was wired and because of the culture in which I live, but none of this had anything to do with helping me cope. Anorexia had a lot to do with self-medication and my brain somehow figuring out the adaptive functions of prolonged malnourishment.

Perhaps these thoughts are little more than semantic hair-splitting; perhaps they're not. To me, the main difference is how much control and choice you have over your eating disorder. I wouldn't say I have none, because I obviously do right now. Yet when I am in the thick of anorexia, my behavior takes on a life of its own and I just kind of hold on. It's as if my brain has been hijacked, as sure as those planes on 9/11.

It's also true that I do need to learn better coping mechanisms so that there won't be as many adaptive functions for the eating disorder to fill. If I can learn to handle stress better, there won't be that pressing need to have it numbed by starvation. If I can learn better self-esteem, maybe I can find something more important to get out of bed for than the hopes of losing weight. If I can find fulfillment in life, maybe I can enjoy that full feeling after a meal without immediate thoughts of guilt and recrimination rushing in.

There is a place for learning coping mechanisms in recovery--but it's not to replace the anorexia.

In her essay, A Journey Through Darkness, Daphne Merkin writes of her lifelong battle with depression.

Surely this is the worst part of being at the mercy of your own mind, especially when that mind lists toward the despondent at the first sign of gray: the fact that there is no way out of the reality of being you, a person who is forever noticing the grime on the bricks, the flaws in the friends — the sadness that runs under the skin of things, like blood, beginning as a trickle and ending up as a hemorrhage, staining everything. It is a sadness that no one seems to want to talk about in public, at cocktail-party sorts of places, not even in this Age of Indiscretion.

Much of her piece focuses on how she ended up at a psychiatric research hospital in New York City, on a unit housing depression patients and those with eating disorders. Her take on her eating disordered inmates was interesting. Merkin said this:

From the very first night, when sounds of conversation and laughter floated over from their group to the gloomy, near-silent table of depressives I had joined, I yearned to be one of them. Unlike our group, they were required to remain at lunch and dinner for a full half-hour, which of necessity created a more congenial atmosphere. No matter that one or two had been brought on to the floor on stretchers, as I was later informed, or that they were victims of a cruel, hard-to-treat disease with sometimes fatal implications; they still struck me as enviable. However heartbreakingly scrawny, they were all young (in their mid-20s or early 30s) and expectant; they talked about boyfriends and concerned parents, worked tirelessly on their “journaling” or on art projects when they weren’t participating in activities designed exclusively for them, including “self-esteem” and “body image.” They were clearly and poignantly victims of a culture that said you were too fat if you weren’t too thin and had taken this message to heart. No one could blame them for their condition or view it as a moral failure, which was what I suspected even the nurses of doing about us depressed patients. In the eyes of the world, they were suffering from a disease, and we were suffering from being intractably and disconsolately — and some might say self-indulgently — ourselves.

Except people with eating disorders are blamed for their illness, when it is even seen as an illness. Eating disorders are generally seen as some sort of failure--if not the sufferer, then clearly her parents. What else could create those fears of growing up? What else could create that pathological need for control? What else could make someone literally die to be thin?

Here's the thing, though. Both depression and eating disorders are illnesses. Sufferers are neither victims of society nor of themselves. They are victims of a frazzled brain, one that warps their perception of the world, that makes them hopeless and frightened. They need sympathy, not pity. Understanding, not blame.

I found it interesting both how and why Merkin found the ED patients "enviable." Some of it was clearly their youth, the hope and promise for the future. Some of it, too, might have been the visual reminder of the seriousness of their illness. I rarely felt I had the "right" to be sick because I didn't always look the part. Who could take my suffering seriously? How could I have an eating disorder? Depression, I would imagine, is the same way, with no outward confirmation of the internal struggle.

The essay is a haunting look at a lifetime of depression, and it resonated with me on many levels.

A post titled "10 Ways to Celebrate Earth Day" on PsychCentral really got me tweaked. Most of the suggestions were good ideas and had a legitimate environmental focus. However, suggestion #3 caused my blood pressure to spike just a bit.

3. Talk with your doctor about alternatives to prescription medication.
Yes, I know this isn’t an option for everyone, but for some alternatives like exercise, talk therapy, and natural remedies work just as well as what comes out of those little bottles. Need some ideas? Check out yoga and sports therapies.

Certainly medication isn't the only option to treat depression, nor should it be. Both exercise and talk therapies have been proven effective against depression; as a rule, I steer clear of "natural remedies" unless they've been thoroughly researched. So I get that people should consider ALL options for treating depression, including medication.

What got me was not the suggestion of alternatives. What really got me tweaked was that this would only be suggested for a mental illness. You wouldn't tell a diabetic to try "insulin alternatives" to try and save the planet. Or screw the statins, Dad, just do some yoga. And chemotherapy might not be so Earth-friendly, either, so let's go play kickball instead. People wouldn't say this.

I am really sick and tired of people pooh-pooing treatments for mental illness that we know work. The author technically said "I know this wouldn't work for everyone but..." but it's the idea that no one would say this for any other type of illness. These are specifically blogs about psychology. Shouldn't they know better?

It seems that people who take medication for mental illness are almost seen as less-than, for not being able to "tough it out" and "pick themselves up" without the help of a pills "in little bottles." I don't like this. At all. Because it's just not true.

Diagnosing an eating disorder usually involves a measurement of height and weight, and then some basic questions: how much do you eat? Do you binge? Do you purge? How much you exercise? Do you think you're fat? If you're seeing a therapist, you may have to fill out a questionnaire, like the EAT-26. If you're seeing a doctor who is decent, they may check your bloodwork and if you're really lucky, do an EKG.

The problem is that this doesn't always catch everything. Why? The DSM-IV isn't foolproof. It's more of a description than a diagnosis, made more for people in their late teens and into adulthood than for younger sufferers, and even some older ones. Many young children with EDs may not express a phobia of fatness, and this is causing many GPs to miss the diagnosis. Nor do people from non-Western cultures always express a weight/fat phobia, although this phobia is slowly increasing. Furthermore, the amenorrhea criteria for diagnosing anorexia has become increasingly controversial, and recent research suggests that we scrap the criteria entirely.

Moreso the questions about how much you eat and how you feel about your body may not always elicit the most honest of answers. Many sufferers (myself included) think they eat just freaking fine, dammit even when their calories are less than 1/4 what is recommended for healthy women. And even when sufferers do realize that their eating habits and body weight give them an eating disorder diagnosis, many don't want help or are deeply ashamed of their abnormal behaviors. Eating disorders do not lend themselves well to honesty. A brand new study is looking at what particular feelings and emotions help distinguish between women with EDs and women without them.

So when I see research about diagnostic brain scans for PTSD and depression, I get excited. Although these brain scans are still a long way off from being used in eating disorders, there is an increasing discussion about their potential use in research and diagnosis. These scans can bring a level of objectivity to the diagnosis. They let both treatment providers and sufferers see what's going on. They might relieve the sufferers of the compulsion to lie about ED's torment.

With the growing awareness of PTSD in the military, some psychiatrists are beginning to wonder at how well current criteria for PTSD are capturing the actual cases of PTSD in the military. Do the current standards exclude too many sufferers? Or could they be too inclusive, lumping people with sub-clinical symptoms into a full PTSD diagnosis that becomes a self-fulfilling prophecy?

I wonder the same about eating disorders. So many times, the media speaks of an "epidemic," yet we don't have the cold hard numbers to indicate this. Certainly, EDs are being diagnosed more frequently in younger children, in men, in minorities. But we don't yet know whether they were there to begin with and we just missed them.

There is so much we don't know about eating disorders, and a good place to start would be better, more comprehensive diagnostics.

I switched around some of my psych meds today, as the previous combo had lost a bit of its normal "oomph." And they messed with my sleep habits (however un-habitual they are), so I decided it was time for a change.

I'm starting back on Prozac. My psychiatrist presented me with several options, and part of me initially shied away from Prozac because it seemed so cliche. Girl gets sad. Girl takes Prozac.

Except, of course, sadness ain't depression. Not by a long shot.

I don't want to have to take meds and know that I will likely need to keep taking them for the rest of my life. I don't do well without psych meds. That being said, diabetics don't do well without insulin and while it might be a pain to stick yourself with a needle several times a day, the alternative sucks. Same here. For me, it's more of the idea of being dependent on some little pill, a little organic molecule, just to get out of bed in the morning.

And this got me thinking: I'm lucky enough to have treatment providers and family and friends who understand that my depression, anxiety, and anorexia are biologically based mental illnesses. Granted, it took some of them quite a long time to understand this and even longer for some of them to get beyond the "you can just snap out of this" mentality as well. I'm also lucky enough to be able to understand and access some of the latest research.

If I'm having this difficulty accepting my illnesses and the need for medication, what must it be like for other people?

Maybe Prozac is cliche. Maybe it is overprescribed- I don't know. But that doesn't mean it's not necessary for me and for others like me. I am trying to be grateful that effective treatments for depression and anxiety and anorexia exist, period, however cliche it may be and however much I may resent needing the treatment.

Really, it's just a pill. It's not a judgment of me or my ability to cope. Nor is depression a reflection of my character. It's the hand of cards I got, the genetic luck of the draw, and sometimes you just have to suck it up and start playing the hand you've got.

I love analogies and metaphors. Love 'em. So when I saw a post titled "How depression is like the X Files" on the World of Psychology blog, I was kind of intrigued.

Before I get too much further, let me add a full disclaimer: I have never seen The X Files. It doesn't seem that interesting to me, and my innate skepticism keeps the whole "aliens are amongst us!" part of the plot from getting me hooked. But even I understood this post and found the metaphor quite wonderful.

Blogger Erika Krull writes:

They [Mulder and Scully and co.] can’t tell anybody, they don’t know who to trust, and whoever they do tell surely will think they are crazy. Really, who would ever believe that the informant who is trying to feed the agents helpful information really has the scar from a metal chip in his neck because he’s an alien hybrid? Even though all the viewers and the key cast members know all about this threat, the agents never seem to know who they can trust. They live in a world of worry, peril, secrecy, and confusion.

Ta-da. There’s my connection. I have often said to myself that my depression felt like an alien had taken over my brain, though the takeover wasn’t complete because I still knew that I was me. I was just disabled enough to have little control but aware enough to realize I wasn’t able to get the alien out by myself.

I needed help. This wasn’t normal; I knew something was different. But what? And how do I describe this? Would anyone believe me? And would I wish I would have kept my mouth shut once I said something? How will this affect my job, my kids, my marriage? I can’t keep going on like this, but I don’t know if I can tell anyone either. Which is more dangerous?

This perfectly describes my experiences with basically any mental illness that I've had (and the list is long, kids. The list is long). For me, though, the "alien takeovers" where I've felt the most bewildered and confused have been with OCD and with anorexia. When I first developed full-blown OCD in middle school/high school, I had mostly obsessions. I was paralyzed by anxiety, and yet I didn't feel I could tell anyone. My fears were either correct, or they were wrong and I was crazy. I knew my obsessions were bizarre- who would believe me? Half the time, I didn't even believe myself! But I was so worried that I could be right that I kept on obsessing, and later added the compulsions.

When I first got sick with anorexia, I didn't realize I was in an "alien takeover" situation. I thought I was fine and dandy- everyone else had those problems. I would imagine that my parents felt an awful lot like Mulder and Scully, trying to convince people that I did, indeed, have a problem. Many other caregivers have probably had this same situation, especially in the first days before the eating disorder becomes patently obvious to anyone who cares to look.

Now that I'm more healthy and more aware, the anorexia is much more frightening. Not always, of course, but I think that fright is healthy. I can perceive when I am starting to loose control a little bit quicker. I am trying to identify which thoughts are from the healthy (or trying-to-be-healthy) Carrie, and which are the voice of Ed. They're not always that different, which is also really frightening. That's probably how I got in trouble with the exercise this past time.

I ultimately have to keep the "aliens" at bay, and learning how to respond when I sense they're trying to take over my brain is probably going to be a key part of that.

I've been wearing The Boot for several days now, strapping it on each morning, and only taking it off for bed. This has also meant full exercise restricting so that my foot can heal, which is far tougher than dealing with the quirks of having the lower half of your leg covered in plastic and Velcro.

My mood this week has taken a definite downturn, without the (fleeting) boost it received from all of those endorphins. And I feel restless, edgy, anxious...lazy. All of these are signs of exercise addiction, which is hard for me to accept. I don't want to believe it, but that doesn't make it any less true.

I fit the profile of a person who would struggle with compulsive exercise, not the least due to the compulsions in other areas of my life. And yes, this does appear to be true in others, as researchers have suggested that AN with compulsive exercise shows many characteristics of OCD.* Furthermore, people who exercise in response to negative moods show more eating disordered behavior and psychopathology than those who don't.

Which makes sense. That endorphin rush doesn't last forever, but our memory of it lasts quite a bit longer. The solution? Exercise more, again, harder. And eventually, the system spirals out of control and you end up with a busted foot.

Of course, lots of people regularly perform high levels of exercise (professional athletes come to mind), that don't result in exercise dependence or addiction. What seems to separate these people from those with an exercise addiction is this:

The experience of intense guilt when exercise is missed and exercising solely or primarily for reasons of weight, shape or physical attractiveness, were the exercise behaviours that most clearly differentiated between women with eating disorders and healthy women.

Ummm...check and check.

This is clearly something I have to deal with and figure out a way to fit in healthy activity without overdoing it. I will probably always have to be vigilant about my activity levels from now on, just like I have to for food. Right now, I'm doing okay with not exercising because I have The Boot and there's this external validation. But I worry about the emotional backlash once I get the all-clear.

There's time for that later, and also time to figure out a way to cope with that. I think it's time for a new hobby.

*If anyone has access to the full text of this article and wouldn't mind passing it along to me at carrie [the little at symbol] edbites [dot] com, that would be great. Sorry for the convoluted email address, I just get heaps of spammers trying to sell me drugs for another condition that can be abbreviated "ED."