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.

I'm a writer, so it might seem kind of odd that I have trouble expressing my emotions verbally.  But there you have it.  It drives my mom bonkers that I don't like to talk when I'm upset.  She wants to help and I'm as closed as an emotional clam.  This isn't always good--I often hold things in until I snap--but I often find that I don't need to process emotional stuff out loud.

I've never been one to wear my heart on my sleeve.  I'm a terrible actress because I find the thought of being emotional in front of others terribly embarrassing.  So verbal displays of emotion with anyone besides my cat is pretty darn rare.  When I used to read those little magazine articles about "How to communicate with a human male" or how men respond to problems, I always laughed, because they seemed to be describing me.  I enjoy helping others with their problems, and listening and problem-solving, but when it comes to being the actual person with the problem?  I'm not a talker. 

For the therapeutically inclined, not liking to talk about your feelings is pretty much anathema.  Maybe it's why I like CBT, DBT, and ACT so much.  But this recent thread got me thinking about how I can express myself non-verbally.

For one, I've always been better at writing about my feelings than talking about them.  For another, there are so many ways you can deal with emotions, even strong intense emotions, without words.  Some people love art.  Others clean when they get stressed.  I like to crochet or blog.  I also love cleaning out my drawers, closet, etc--it's like emotionally purging.  Getting out on my bike really helps clear my mind and let's me be more rational about what's upsetting me.  Being outside period is therapeutic.  So are crafty things like making jewelry and sewing (I swear I'm not a reincarnated version of Donna Reed. I swear).

Some of my old therapists liked to link my seeming emotional constipation with my eating disorder.  If I could just talk about my feelings then I wouldn't need to use ED symptoms.  Except, of course, I did my best to hide the ED symptoms, which meant that I couldn't be using them to communicate.  Nor did anyone bother to ask whether I was this way about emotions long before the eating disorder surfaced.  But I digress.

Rather than expressing emotions, I think the important thing is to accept, understand, and process them.  Verbally is fine.  So are non-verbal methods.  What do you think?

How do you deal when words fail? Share your thoughts in the comments!

In my recent post on living life with an active voice, my friend Angela pointed out that recently, I had begun to post more authentically, and (this is perhaps what stood out the most for me) I wasn't intellectualizing everything and hiding behind it. Intellectualizing everything is a habit I've had for years. Everyone knew me as The Smart One. I wasn't good at sports, I wasn't good at art, I was decent at music but far from the next Mozart or even American Idol. I also wasn't really bad at anything- I didn't achieve renown for being the Bad Girl or She Who Sucked At [fill-in-the-blank]. No, I was the Smart One, and I fell into the role rather eagerly. Social interactions were never my strong point, but I could handle brainy stuff.

Not surprising to think that this followed me into my eating disorder.

I thought a lot this past decade about recovery and anorexia. I did research. I read books. I talked to experts. And then I thought some more. I never really lacked insight--but I did lack skills for reaching out to others, for shoring myself up in ways that didn't require extensive brainpower, for dealing with the emotional messiness that accompanies an eating disorder. Simply put, I tried to think my way out of my eating disorder.

An oh-so-helpful reviewer of my first book wrote that I was doomed to relapse because I intellectualized everything. Besides the fact that I had relapsed already by the time they posted their comment, my basic response teetered between "You don't know shit about me" and "So I intellectualize everything? So what?" Yes, the spirit of the comment wasn't necessarily friendly or helpful, but the person did have a point. What I struggle with is how not to intellectualize everything. Outside of the eating disorder, I'd have to say my intellectual side has served me rather well.

But there's still that eating disorder. It's still here. Maybe not as severe as it has been, but it's here. I don't know what role my constant intellectualizing plays in my ongoing saga, nor am I exactly sure what "intellectualizing" really means. I know that when I want to learn about anger, say, or depression, that I look it up on Google or in PubMed. I can tell you about brain abnormalities and neurotransmitter deficiencies and excesses, but here's the thing: when I get mad or sad or anxious or any number of emotions that make me feel ick (read: like using ED symptoms), I don't know what to do. One of my good friends, who happens to have severe anxiety, asked me how I coped. I blinked and answered: the eating disorder.

Anorexia was my ultimate intellectualization. I could justify anything in that state. I didn't have to feel; I barely had to exist. My body was beside the point. I saw starving myself as this battle of mind over matter. I could think my way out of any problem, because I could figure out a way to make Situation A turn into Result B, which was restricting and losing weight.

I need to stop hiding behind my brains. I know I'm smart, although I don't often feel smart. That's not the point. The point isn't to dumb myself down or to stop thinking about things. The point is to stop neglecting my emotional side (assuming, of course, that I have one! :). To do this, I'm going to focus less on blogging about research stuff and more on blogging my recovery and the issues therein.

I have loved blogging about the science of eating disorders, and I don't intend to stop forever. I also don't intend never to blog about research in the coming months. I often found it useful to use an interesting new study as a jumping off point to explore a new issue, frequently one I never thought about before. I also reserve the right to blog about super-cool, hot off the presses research if the mood strikes me. But for now, I think I need to start focusing on ME and MY recovery rather than research and outreach and awareness-raising.

This week's Science Times in the NY Times featured a profile of psychologist Russel Hurlburt, who studies the inner experiences of people with mental illness. For many mental illnesses, the DSM spells out the symptoms that people have, but it doesn't really describe what it's like to have a particular illness. For that matter, knowing what cancer is and how to treat it isn't the same as knowing what it's like to have cancer and undergo treatment.

From the profile:

After hundreds of introspective interviews, Dr. Hurlburt still hesitates to generalize from his findings. But he has observed that the basic makeup of inner life varies substantially from person to person.

“My research says that there are a lot of people who don’t ever naturally form images, and then there are other people who form very florid, high-fidelity, Technicolor, moving images,” he said. Some people have inner lives dominated by speech, body sensations or emotions, he said, and yet others by “unsymbolized thinking” that can take the form of wordless questions like, “Should I have the ham sandwich or the roast beef?”

In a 2006 book, “Exploring Inner Experience,” Dr. Hurlburt suggests that these differences may be linked to personality and behavior. Inner speakers tend to be more confident, for example, and those who think in pictures tend to have trouble empathizing with others.

Differences in thinking style may also help explain some aspects of mental illness. In studies conducted with Sharon Jones-Forrester and Stephanie Doucette, Dr. Hurlburt found that bulimic women experienced a clutter of simultaneous thoughts that could often be cleared by purging.

Which makes sense to me. If you want to consider exercise a form of purging, I can definitely attest that purging slowed my racing thoughts and really calmed me down. Purging (granted, I have purged in more ways than exercise, but that was my most common and recent form of purging) was almost like dissociating. It's not exactly the same, and I wasn't dissociated while exercising/purging, BUT my brain also felt very separate from my body, almost like it was observing me running or pedaling or whatever.

I tried looking for any publications by Jones-Forrester and Doucette, but it appears that their work on the inner experiences of people with bulimia consisted mainly of doctoral dissertations under Dr. Hulburt. I found the abstract of Jones-Forrester's thesis, which reads:

Inner experience is of crucial importance in bulimia---clearly something experiential leads individuals to binge or purge. We used Descriptive Experience Sampling (DES) to examine the inner experience of bulimia in 5 participants, replicating Doucette (1992). Our participants' inner experiences were largely consistent with Doucette's but were substantially different from what is assumed by the non-DES literature: our bulimic participants had a consistent fragmentation of attention, hypersensitivity to the sensory aspects of experience, affect that is poorly differentiated and often confused with cognition, and a striking lack of cognition overall. These results suggest that DES can be a powerful tool to challenge the assumptions of the extant literature and to expand our understanding of bulimia.

Hurlburt cited the research of Doucette in his 1993 book "Sampling Inner Experience in Disturbed Affect," sections of which are available on Google Books. From this book:

Multiple Inner Experience is the simultaneous occurrence of a few or many separable, identifiable inner happenings, all taking place in inner experience at the moment of the beep. One of the most striking findings in our study of bulimics was that Multiple Inner Experience was a frequent characteristic of the inner experience of all our bulimia subjects. This is in sharp contrast to the findings of other researchers sampling non-bulimic populations, where the phenomenon of Multiple Inner Experience occurs occasionally but is rare (an exception is the example of Borderline Personality described in Chapter 14). In contrast with other subjects, however, Multiple Inner Experience was the rule, rather than the exception, among our bulimics: the frequency ranged from 40% to 100% within our individual bulimic subjects.

It was also the case that, for our bulimic subjects, the presence of Multiple Inner Experience was directly related to the degree of bulimic symptoms: the more actively bulimic the subject, the more multiple the inner experience. This was true both when considering the percentage of a subject's samples containing Multiple Inner Experience (the more actively bulimic, the higher the percentage) and also when considering the multiplicity of experience at any given sample (the more actively bulimic, the higher the number of separate experiences which were reported to be simultaneously occurring at any one beep).

{snip}

A third characteristic experienced by our bulimic subjects was the relatively blurred distinction between thought and feeling. Our bulimics frequently seemed to "think their feelings" or "feel their thoughts." By contrast, most normal subjects in our sampling were very clear about the distinction between thinking and feeling. Even on those occasions where they have difficulty providing the experiential details of a thought...most non-bulimic subjects have no doubt that the thought is a "cognitive" or "mental" experience; the same is true for affective experiences. An exception is our anxious subjects (see Chapter 13), who also at times had difficulty distinguishing between affect and cognition.

{snip}

The intensity of the urge to purge seemed more related to the heightened multiplicity of thoughts and feelings than to the content of food or weight.

(Emphasis mine)

I find this work of Hurlburt, Doucette, and Jones-Forrester to be absolutely fascinating, and I really wish there was more peer-reviewed research on the subject. Still, this work may help fill in the gaps between what we know about bulimia and how BN is experienced.

One of the most profound things I learned in treatment for anorexia was how much the symptoms of my eating disorder (obsession with food, increased anxiety and insomnia, agitation, hyperactivity) were as much symptoms of starvation as they were symptoms of anorexia. Not that this made eating any easier--it didn't--but it helped put a context to all of the frightening thoughts and compulsions I was having. Eating seemed to make them worse, but only after a while did eating make them somewhat better.

Undernutrition may actually be at the core of many of the traits and symptoms researchers initially thought were caused by anorexia. Many people with anorexia are probably more obsessive, anxious, and perfectionistic than average; since these traits existed before the eating disorder, they aren't caused by undernutrition, but they sure can be exaggerated. Even just a quick read of Keys' starvation study indicates that many of the behavior changes brought about by semi-starvation can be significant. Many brain imaging studies of anorexia are performed after weight restoration and a period of recovery and normal eating because starvation has such profound effects on the brain.

There have been numerous studies that have reported on psychological changes that occur during refeeding (Konrad et al 2007), but two interesting studies appeared within the past week that seemed to emphasize the role of refeeding in the psychological recovery from EDs.

The first article was from the French journal Encephale, which looked at the relationship between social phobia, anorexia, and the stage of treatment (Coulon, Jeammet, and Godart, 2009). Because the journal is in French, I'm going to have to stick with the abstract, but the results were still interesting. Social phobia has been loosely associated with AN, but the researchers were trying to figure out whether the social phobia might be a by-product of malnutrition rather than an actual trait of the anorexia sufferer. In this sense, it's kind of the proverbial chicken-and-egg question: which came first, the undernutrition or the symptoms of the eating disorder?

And what did the researchers say about how stage of treatment in anorexia affected social phobia? They found a correlation between social phobia and symptoms of AN as well as "total clinical picture" of the patient, but no relationship between social phobia and nutritional status (as measured by BMI). The researchers concluded that "We therefore feel that a diagnosis of social phobia can only be confirmed after an acute state of AN, thus allowing for preferential treatments. Other studies must be conducted in order to continue to explore the links between social phobia and AN."

This doesn't preclude the pre-illness onset of social phobia--in fact, a 2004 study found that approximately one in five ED sufferers met the diagnostic criteria for social phobia before the onset of their disorder (Kaye et al, 2004). However, due to the eating disorder, social phobia can appear in a person who had no previous symptoms of the disorder. So is that social phobia a true, independent disorder, or is it related to undernutrition? This study says that social phobia might be related to undernutrition, but we don't know for sure yet.

The second study looked at the hypothesized relationship between anorexia and autism spectrum disorders (ASDs; Time Magazine had a good article earlier this year on the issue that I blogged about here). Specifically, the study looked at the difficulties people with AN have with respect to the emotional Theory of Mind (eToM), with understanding and interpreting others' emotions (Oldershaw et al, 2009). People with ASDs often have difficulty understanding other people's emotions, and the fact that AN sufferers also had difficulty with this seemed to be a neurological link between the two disorders.

The researchers compared a group of currently ill AN patients with both recovered AN patients and healthy controls, and found that the emotional deficits seen in acutely ill AN patients had essentially disappeared in the recovered AN patients. Furthermore, there were few differences in emotional tasks in recovered AN patients and healthy controls, which indicates that the emotional deficits are more related to the current state of undernutrition than they are a person's temperament.

Conclude the researchers:

These findings indicate almost complete normalization of emotion recognition ability as well as the restoration of eToM in recovered patients, despite the observation of difficulties in both domains in currently ill patients. Findings suggest that similarities between AN and ASD in poor eToM are restricted to the currently ill AN state and such difficulties in AN may be a factor of starvation.

However, other similarities between AN and ASDs remain, such as difficulties with set-shifting and impaired central coherence (i.e., you can't see the forest because of the trees) that seem to extend long beyond recovery. That, however, is its own blog post that will hopefully be up soon.

A sudden spate of new research on emotions in anorexia nervosa has definitely caught my interest, as emotions are not something that come easy for me. It's not just a feel your feelings sort of thing, but also a "I know I'm pissed and anxious, so now what" kind of thing. I feel emotions and I feel them hard and deep. I can usually identify them, but regulating them and living with them isn't one of my strong points.

A new study, titled "Emotion avoidance in patients with anorexia nervosa," found a strong relationship between levels of emotional avoidance, anxiety, and ED psychopathology in people with AN.

"Patients with AN endorsed levels of emotion avoidance that were comparable to or higher than other psychiatric populations and exceeded community controls...[These] findings confirm that emotion avoidance is present in patients with AN and provide initial support for the idea that anorexic symptoms function, in part, to help individuals avoid aversive emotional states."

Which makes a lot of sense. Anxiety is quite possibly one of the biggest triggers I have, and not eating makes me feel less anxious. And the strong relationship between anxiety and eating disorders hasn't gone unnoticed. Walt Kaye's group out at UCSD found this to be true experimentally.

Another study, titled "Emotional processing in women with anorexia nervosa and in healthy volunteers," found that

"Compared to the [healthy volunteers], patients with AN had lower levels of self reported emotional awareness and expression. They also responded more slowly to, correctly identified fewer emotions and misclassified more emotions in a facial recognition task, and responded more slowly to, and recalled fewer, self-referent emotion words."

Previous research has suggested that adolescents with anorexia had impaired emotional processing compared to non-anorexic adolescents.

A study from earlier this year, "Emotional perception in eating disorders," found that

"Patients with AN-R showed increased fear when confronted with stimuli containing anger, whereas patients with BN showed a tendency towards decreased fear...The finding of increased fear when exposed to the emotion of anger might be attributed to introversion and conflict avoidance of anorectic patients."

Which I have again found to be true in my personal experiences. Anger, whether mine or anyone else's, tends to terrify me. I typically avoid conflict, but my mom has also described me as "scrappy" at times, so it's not a 100% thing. I'll charge in if no other alternative is open, or if I'm feeling quite peeved, but usually, I just stay in the background. Some of this hanging back is conflict avoidance, and some of it is my innate introversion.

Other, more qualitative, studies have also looked at emotion perception in anorexia nervosa and the use of emotion-focused therapy to treat AN. I don't find either of these two studies as promising as the first three, largely because the results don't seem to be as concrete or reproducible.

Regardless, issues with emotion processing and recognition are neither purely genetic or purely environmental but arise from an interaction between the two.