I've gotten back on track after my struggles a week or two ago, and it got me thinking about the idea of momentum.The first few days of getting used to eating on a regular schedule were really difficult--stressful and anxiety-provoking. But as these positive behaviors gained momentum, it became much easier. It's still not quite as easy as before I slipped a few weeks ago, but it's getting there.

Recovery behaviors have momentum, and so do ED behaviors. How many of us have done something "just once" and really, truly meant "just this once"? My hand is raised like Hermione's. But behaviors have momentum, and just once becomes just twice becomes a routine.

I picture behavior momentum as a hill: recovery behaviors are going uphill, ED behaviors going downhill. Illustrated as follows:

I'm thinking back to my college physics class (it was a nightmare even for geeky me, so I will try to keep this as short and basic as possible) when we studied acceleration and momentum. A few days ago, I bought one of those jumbo boxes of kitty litter at Costco, and pushed it out to my car in a shopping cart. The parking lot had a slight hill, and I had to really push hard at the cart to get it started up the hill. I was fighting gravity, and I had to accelerate the cart to get it up the hill. This required no small amount of effort, also considering I had other heavy stuff in the cart. But once I got the cart going--once it had a certain amount of momentum--pushing it up the hill wasn't particularly difficult. Turning or stopping were...interesting, but just pushing in a straight line was simple.

It's the same with recovery: once you push through the initial effort, recovery behaviors gain momentum. They get easier. It doesn't take the same amount of effort to do the right thing.

Relapse behaviors are going downhill. It takes much less to get that momentum building. If I had poised my cart at the top of a hill and just given it a nudge, it would have sped off on its own. And stopping a speeding cart would have been much harder the more speed the cart gained. So it goes with an eating disorder. Relapse takes less effort and is harder to stop. It tends to gain momentum much faster than recovery.

For some reason, having that visual image in my head has really helped me. It lets me stop fixating on why recovery is so damn hard and simply focus on pushing the massive box of kitty litter up the hill. It also makes me more cautious when I'm teetering at the top of the hill.  Being close to speeding off is very different from, you know, actually speeding off. In the end, it's all about building the kind of momentum you want in your life.

This is actually a post I've been meaning to write for a while: the curious upside to relapse.

Before I go any further, let me say that I don't advocate relapse, I'm not saying you should try to relapse just to "see what it's like" or to stare the demon in the face and see who blinks first.  I'm also not saying relapse is inevitable.

It is, however, exceedingly common.  So common that I don't know anyone who has recovered without at least a minor relapse.

But here's the thing: although a relapse isn't good, it's also not 100% bad, either. Your first task when you find yourself slipping is to pull yourself out of the hole. Then, I've found it helpful to identify triggers and potential turning points where I could have done something differently.  From a number of these dissections, I've learned some things that have ultimately helped my recovery.

1. Relapse can show you where your recovery is weak. For some people, it's PMS. For others, it's work stress. Or kids. Or breakfast. Or whatever. These things can be easy to overlook or shrug off.  But a relapse can give you a chance to address these, head-on.
2. Relapse can force you to re-evaluate your goals. Maybe you love your job but it's stressful as hell, and a relapse is showing you that all that stress isn't healthy. Or that your college major isn't what it's cracked up to be. Relapse can be an opportunity to rethink things with a fresh set of eyes. If high stress and low sleep are demanded by your job or major, it might be time to rethink just how much you want to be on that path.
3. Relapse can remind you just how bad the illness is. We forget, sometimes, just how crappy we feel when entrenched in the eating disorder.  But a period of wellness followed by a return of symptoms helps drive home the difference that recovery can make.
4. Relapse can be humbling. Humbling in a good sense. It's easy to think that we'll be fine, that there won't be any problems, that we don't need extra help. And then comes a little friendly reminder that we do, in fact, need support and lots of it.
5. Relapse can let you refine your treatment. It's easy to coast through and think that everything is fine. And it's hard to see the need for change when things are going well.  Obviously--if things are going well, you don't want to change that. But a relapse can be the extra nudge you need to switch medications or therapists, try a new treatment approach, or otherwise shake things up.

The idea isn't to just let relapse happen. If it does, however, you can use the experience to build up your recovery, rather than using it as an excuse to let everything decay.

What are some of the things you have learned from relapse? Share in the comments!

One of the things I'm struggling with a bit right now is balancing how far I've come with how far I still need to go.  Thinking about how much more work still needs to be done is rather overwhelming--but that doesn't change the fact that it's ultimately still rather necessary.

I read an interesting blog post on Psychology Today titled How to Become a Great Finisher.

Some interesting bits of the post:

Koo and Fishbach's studies consistently show that when we are pursuing a goal and consider how far we've already come, we feel a premature sense of accomplishment and begin to slack off. For instance, in one study, college students studying for an exam in an important course were significantly more motivated to study after being told that they had 52% of the material left to cover, compared to being told that they had already completed 48%.


When we focus on progress made, we're also more likely to try to achieve a sense of "balance" by making progress on other important goals. This is classic Good Starter behavior - lots of pots on the stove, but nothing is ever ready to eat.


If, instead, we focus on how far we have left to go (to-go thinking), motivation is not only sustained, it's heightened. Fundamentally, this has to do with the way our brains are wired. We are tuned in (below our awareness) to the presence of a discrepancy between where we are now and where we want to be. When your brain detects a discrepancy, it reacts by throwing resources at it: attention, effort, deeper processing of information, and willpower.


In fact, it's the discrepancy that signals that an action is needed - to-date thinking masks that signal. You might feel good about the ground you've covered, but you probably won't cover much more.

I don't think the author is saying that a feeling of accomplishment is bad, but it can be premature. I've met many people who tell me how much more they're eating than before, or how much less they're purging. Which is all well and good (it really is), but when you're still regularly undereating or purging or engaging in any other ED behavior, there's still a massive problem. Yes, you've made progress and give yourself a pat on the back, but (and this is the hard part) don't stop there!

When you're doing something as intense and lengthy and grueling as ED recovery, it's easy to want a break and get complacent.  Taking a little time to breathe and regroup is one thing (my friend Charlotte reminds me, and everyone else, to breathe regularly); but you also can't stop forging ahead. 

A metaphor I love came from the preface to Laura Collins' Eating With Your Anorexic. Psychologist James Lock writes that recovery is like climbing a sand hill: if you stop, or don't get all the way to the top, then you'll slide back down to the bottom.  Although acknowledging how much progress you've made is wonderful, it's also important to consider what's still left to be done.

That's where it gets tricky.  I compare how I'm doing in recovery now to when I was at my sickest, and I just want to say "But look at how much work I've done! Look at how much better I'm doing! Can't I just stop here?"  The problem is that stopping "here" ultimately means a slide backward, and beginning that slog all over again. 

Like so many things in recovery, the answer isn't an either/or question.  It's figuring out to celebrate progress made while balancing that with continuing forward motion.  That being said, I can barely figure out how to walk and chew gum, so we'll see how this multitasking goes...

As the economy began it's nausea-inducing nosedive at the end of 2008, many US banks and insurance companies were loaned money by the government because they were "too big to fail."

This week, as I have been on my own and trying to bull my way through piles of writing and work, I have been hearing the siren call of AN. I wasn't looking for the call, I wasn't seeing it out. But with my routine shaken up a bit with my parents out of town and then visiting my friend for the weekend, I got off track. And sleeping through breakfast yesterday meant that I felt pulled to skip breakfast this morning. Surely it won't make a difference, will it? And lunch. Who really needs lunch, anyway. Think of all of the writing I could get done.

I did eat breakfast, and lunch, but not nearly enough. I knew this should have been a big red flag--a red light sign in my relapse prevention plan--but I felt strangely not bothered by this. I wasn't particularly hungry, and eating seemed like such a damned inconvenience.

Apparently, I was bothered by this at least somewhat because I mentioned it to TNT at our session today. Not in the on-my-way-out-the-door, at least I can assuage my guilt about lying sort of way (admit it--you've done it, too!), but in a way where I actually sought out feedback about what was happening. We discussed what I needed to do to get back on track (eat a meal plan compliant dinner and evening snack, both of which I did) and then plan out my meals for tomorrow.

We also discussed where I was in recovery, about my blossoming writing career and all that I want to do professionally. About the fact that I really, really want to get my own place and pick out paint colors. About how I want to travel to the Galapagos and Australia. I have a fighting chance at a real life now.

Like the banks that were too big to fail, I have too much to lose now.

Before, all of these wishes and dreams were so nebulous and ephemeral that I could shrug off their loss. I mean, I'm not going to own a Mercedes, either, and I'm not exactly bothered by that. But now, my dreams and my life are so much closer. They're realer (if that's a word). I'm making them happen, right now. I can't continue to make them happen when I am deep into ED. I won't be researching how bacteria can smell, I will be looking up calories in food and determining how much I need to exercise and staring at recipes all day long.

My last relapse brought me face to face with the stark reality that I couldn't have what I wanted in life and also have my eating disorder. I had to choose.

And I chose life.
I chose life and I didn't look back.
At least, I haven't looked back very often.

TNT told me I had worked my ass off to get where I am in recovery (I turned around, looked down, and said, "No, I didn't. My ass is sadly still there."). There's the reality that I always have another relapse in me, but I don't know if I have another recovery.

So I ate.
And hated myself.
And then forgave myself.

Eating can be an inconvenience, but relapse is a bigger one for me right now. I have stories to write and condos to find and places to go and dreams to fulfill. My ED is not part of this--it never was.

When I drive to TNT's office each week, I have to turn the opposite way on the road that I usually take to my job at the bakery. This past Saturday, my appointment was earlier than usual and I was running late, so I had many different things on my mind, the least of which was the roads I needed to be driving to TNT's.

I'm guessing you can tell what happened next: I took a wrong turn. Already late, I kept driving like I was going to work instead of to my therapy appointment. I realized my mistake right as I had committed to the wrong turn, but by then, it was too late. I had to keep driving until I could get to a place to turn around. Which I did, and with a little help from my lead foot, I arrived to my appointment with TNT on time.

The moral of the story isn't driving directions and how I shouldn't be trusted to follow them, the moral of the story is about when habits get ingrained. Of course, we all have habits, and habits can make life more livable. If we had to think about every single decision we made, all we would do is sit around and make decisions. (And by "we," I mean the royal we, as in me, myself, and I. You should know better than to let someone with OCD make a decision.) So we have habits and operate on autopilot. This, in and of itself, is not a problem. The problem is knowing when to stop living on autopilot.

One of the really good times to stop living on autopilot is when you're doing something completely different than what your autopilot is used to doing. Such as driving to therapy instead of work. Or eating lunch instead of exercising. Autopilot says "Turn right!" and "Go for a run!" Okay, fine. No big deal. But if I'm not aware I'm operating on autopilot, I'm going to go ahead and turn right and go for that run when I should be turning left and having a sandwich.

When I was driving to see TNT, I wasn't aware that I was driving on autopilot. I don't always consciously think about where I'm going, but I also don't think that I'm not actually thinking about where I'm going, either. On Saturday, clearly I wasn't thinking about where I was going. I was just driving. If I had been headed to work, there wouldn't have been a problem. This past Saturday, though, I was doing something a little out of the ordinary and I should have paid attention to where I was going.

What I've come to realize in recovery that it's not the presence of ED thoughts that gets me in trouble. My problem is when I stop paying attention to whether these ED thoughts are subtlely influencing my behavior. Of course, this can lead to hours of rumination and perseveration on "is-this-ED-or-is-this-me," but I also can't be deliberately unaware of it, either.

A lot of the inspirational and self-help literature says to live life with intention, and I don't disagree with that. But sometimes, you just need to get from point A to point B and autopilot is just fine for that. When you're trying to find your way out of a tropical jungle with no compass and no map, however, it might be a good thing to start paying attention.

No, I'm not talking about my own relapse. I'm talking about my cat's.

I picked up my cat from boarding at the vet's for the past two and a half weeks, and I was over the moon to get her back. Aria and I are rarely separated, and it was nice to have my best friend by my side again. When I got her home, I let her out of her carrier and picked her up. I saw her leg and my heart sank. Aria has an autoimmune skin condition that makes her leg itch, and she bites at it until the fur is gone and her leg is raw and bleeding. She's on a low dose of steroids to help keep it under control (I tried numerous alterations in her diet, to no avail) and it has been for quite some time. Not right now, though. It flared up again at the vet's.

Assuming they gave her the medication properly, I can understand that Aria was stressed, and the stress can lead to a flare-up. Even if they did everything properly--even if--how did they miss the fact that so much of her leg was raw and weepy? I picked her up and it was the first thing I noticed. Did they not check on her properly?

I called the vet's office and spoke with someone who assured me that Aria's medication was given properly, but they couldn't explain how someone failed to notice that her condition had gotten worse. I wanted to throttle them. This wasn't just any cat--this was my baby! How could they have let this happen? She had been doing so well when she was home with me, and then she leaves and all hell breaks loose.

Somewhere around this point, when I am simultaneously heartbroken and livid, I realize that this must be a bit what it is like to watch someone struggle with an eating disorder. It must have been baffling to my mother how so many people missed spotting my eating disorder when I was sick. It was right in front of them, under their noses and rather obvious, and yet as my illness got worse, everyone claimed to be caught off guard. And then to have had your loved one do so well while at home and safe, and the second your head is turned, bam!

I also better understand the impulse my mom had to bring me home and help me get well. It's not pathological and over-controlling, it's the response of someone who loves their kid and desperately wants them well. That's what Mommies do.

Aria is (hopefully) on the mend. Her injury doesn't look as red and sore, so I think she's stopped biting at it. Now we just need to let her leg heal and find her another vet--one who isn't negligent.

When I was taught about avoiding ED triggers in treatment, I learned a lot of the usual: stay away from fashion magazines, the crazy aunt/sister/cousin/uncle who's always on a diet, throw out your "sick" clothes, etc. All of these are very good things to do, and I've made changes in all of these areas in my life to avoid being bombarded with the same messages that I'm trying to convince myself aren't true.

Where I'm at in recovery now is a little different from when I was first hospitalized almost 9 years ago. Sure, my body image may take a hit if I look at a fashion magazine, and nothing sets my teeth on edge quite like discussion of what I "should" be eating. It's irritating and uncomfortable, but it's not triggering. It doesn't make the ED sound all rosy and happy and maybe breakfast really isn't such a good idea after all.

This is not to say that I'm without my triggers, however. They're just a lot different than some of the ones I learned so long ago.

My biggest trigger, without a doubt, is anxiety. The more anxious I get, the more I feel compelled to return to my routines and rigid ways of living. It makes me want to do an impromptu ultra-marathon and run until I'm too physically exhausted to be wound up and anxious. It's what ultimately prompted this last relapse: heaps of unchecked anxiety that I "managed" by exercising and creating more and more rules for myself until I was sucked back in.

I've been making a lot of progress recently with feeling more free to eat when I'm at home. The AN isn't gone, but I can exhale just a little bit. I don't get the insane metabolic hiccups anymore (as in needing nearly twice the daily recommended intake just to maintain), and my body is beginning to trust that food will be there again in a few hours. Part of the exhalation is my routine. What I do, when. Particular combinations of foods. Even just the types of food that are generally on hand. When I arrive in a different environment--even a comfortable, different environment--I get all shook up. And those nagging fears creep back in, fears about whether I'm eating too much in general, I'm consuming too many "added sugars," I'm exercising enough, what will be served in a few hours.

Right now, it's a fine line between finding security in the routines that I psychologically crave, and not getting so wrapped up in them that it ends up hindering my recovery. These routines do help dramatically decrease my anxiety, which then helps me stay in recovery. On the other hand, if the slightest deviation in my routine causes me to freak the hell out, this isn't good, either.

I think tackling my longstanding anxiety and depression will be one of the last major hurdles for me in recovery. I'd love for it to be short and easy and simple, but I have a strange feeling that's not going to happen. But until I do, those triggers will always be waiting for me.

One of the questions I get a lot when people hear about my eating disorder history is usually some variant on: but how did you resist all of that tempting food? (This is usually said dripping with the unsaid phrase of "please teach me how you did this.") My answer is that anorexia made me afraid of food. Not that I wasn't hungry or wasn't utterly obsessed with it, just that the prospect of facing food gave me that deer-in-the-headlights feeling.

Now, if we want to talk about temptation, we can talk about the allure of the anorexia symptoms. I'm not so delusional as to think that losing weight will be a cure-all for everything that is wrong in my life, but I have been so delusional as to think I wouldn't become addicted to exercise, or that I could lose five pounds and be absolutely fine, dammit. Uh, not so much. Eating dinner every day really does matter, and so does making sure I have at least one rest day each week from exercise.

Which is why this study on restraint bias (called The Restraint Bias: How the Illusion of Self-Restraint Promotes Impulsive Behavior really interested me: it seemed to echo my own thoughts that I really wasn't all that vulnerable to relapse. I mean, hey- I've written two books on eating disorders. Surely I'd know the danger signs.

Except that it doesn't work that way.

Ed Yong, in his blog Not Exactly Rocket Science, has a great explanation of this study, and summarizes the study as follows:

The restraint bias stems from the fact that we're generally bad at predicting the future and how we'd feel in circumstances that are different to our current ones. When we're full, we underestimate the powerful pangs of hunger. When we're cold, we can't imagine what it's really like to be sweltering. Addicts underestimate the pull of their drug-of choice when they try to quit.

{snip}

The restraint bias could also help to explain why people willingly take up activities they already know to be addictive - they simply believe that they're strong enough to resist the addiction. As a powerful example of this, one study showed that heroin users are less willing to pay for the substitute buprenorphine if they weren't currently experiencing cravings. If experienced users underestimate their urges, imagine how monumentally more difficult it would be for a naive person to do so.

Restraint bias is the idea that we often think we are better at resisting temptation than we really are. A smoker may underestimate the strength of their cigarette cravings when they're in a smoky bar. Someone with binge eating behaviors may take home leftover cake for their family to enjoy, pretty sure that they won't be tempted to eat it. Or, like me, you may think you can skip dinner once and it won't become a habit. Or that you will pack your schedule full of activities and jobs, positive that you will still find time to eat.

This is really life's way of knocking you on your arrogant ass, over and over and over again. And the only way to deal with this restraint bias is to learn humility. To accept that one skipped dinner is never just one skipped dinner. To be always aware of the pull of this behavior. This is not to say that full recovery isn't possible. I know there are plenty of people who are completely free of eating disordered thoughts. But efforts to stay recovered and healthy are different than efforts of constantly fighting off an illness.

I never thought I couldn't relapse or wouldn't relapse, but I sure thought it would be more difficult than it was. Looking back, I can see that I was teetering on the edge of a relapse for a good long time, and that it didn't take much to push me over into the "let's starve!" mode. I underestimated how rapidly exercise would become addictive, and how difficult it would be to just stop. I didn't realize that I couldn't just flip a switch in my brain and start eating again. Which is restraint bias at it's finest.

My recovery journey has been humbling and, at time, humiliating. But I think that ongoing self-awareness will help keep me well, and keep me on my toes.

For carers of those with eating disorders, the line is often-repeated that you need to put your own oxygen mask on before you can help your child with theirs. And in that context, I read about An Encounter With Hypoxia. However, as I read it, I didn't think about caregiving, I thought about relapse and recovery.

Think of the hypoxia symptoms as a relapse or a slip. Sometimes these symptoms are straight out of the textbook; sometimes they're more unusual. Sometimes they come on slowly; sometimes they just give you a proverbial kick in the gut--you go from fine to f*cked in less than 10 seconds. In treatment, I was told what these symptoms were, and I could probably do a decent job at recognizing them in others. But when it came to me, I was clueless. Reading about relapse and then actually experiencing it are two different things.

This past spring, I was aware for a while that I might be getting into dangerous territory, but I felt fine, so I just kept living my life and flying the metaphorical plane. By the time I realized I was relapsing and needed my oxygen mask, I was too far gone to put it on myself. Looking back, I can see the signs and identify several places when I really should have stopped flying the plane and started making sure that I had enough oxygen.

Which is why slips and struggles can be beneficial: they help you begin to recognize when you might need to put on your oxygen mask. I'm not saying people should be thrown to the wolves or left to starve and then polled about their experiences. Nor should you necessarily try to relapse in order to pick up some of these valuable lessons. But there's also something to be said for experiencing recovery hypoxia while you are still in a position to have others quickly put your oxygen mask on. It's how they trained the Air Force pilots, so that when they were out solo, they could recognize the signs before the signs that told them they needed more oxygen.

Part of the hardest thing for me to grasp is just how quickly my symptoms arise and how I'm almost incapacitated even more quickly. How, like Student Number 5 at the beginning of the article, I can be in desperate need of oxygen and not even know it. I don't know what the solution is. Take regular puffs of recovery oxygen and monitor if I feel different? Don't get in an airplane? I don't know what the exact answer is, but I suppose there's no better time to start figuring that out.

I apologize for the lack of posts recently- I've been beyond exhausted trying to box up a lot of the stuff in my apartment and get ready to move back to the Midwest.

My parents arrived on Friday night, and my first thought was: just kidding. I'm okay, really I am. I can't shake the feeling that I'm making a big deal out of nothing, even though all evidence points to the contrary. My therapist dropped the f-bomb when she found out how much weight I'd lost, and the short amount of time in which I had lost it. My arms are furry. My BP is low. My hands and feet and (oddly) left butt cheek will randomly start tingling.

But...but...I stammer...my labs and EKG were normal! I'm not wearing children's clothes! My weight has been lower!

The grim reality is this, though: I can't turn it around on my own. I can't just un-flip that anorexic switch and start eating and gain the amount of weight that I need to. Perhaps on some level I get this, although I don't want it to be true.

In a recent blog post, therapist Erika Krull writes what she tells her clients in situations like this:

“You can think that way about your problem if you like, pretend it isn’t there. Or you can face the truth and acknowledge its existence. Either way, the reality of your problem will still be there. You just have more power to make your situation better if you face it.”

Krull writes:

Usually, facing the truth of a difficult situation is a shorter-term pain than most people anticipate. It can hurt like a sucker punch, but then the best part comes. You get the chance to move forward with your life, leaving behind a clunky dirty piece of baggage that you’ve been dragging around behind you. As long as you keep trying to dress up that piece of baggage and keep it with you, it’s going to keep weighing you down. Call it out for what it is, dump it, and get on to the best part of life. Living with honesty.

This is what I am trying to remember, even as I look in the mirror and cannot for the life of me figure out why people are so worked up, can't figure out why I need to gain when I already feel so fat and gross.

I'm sitting here at work, just crying. Tears of utter gratitude and love. I can't believe the support I'm getting right now. It's just...amazing.

If nothing else, this is what is so different about every other time I've struggled and fallen. Before, I kept it to myself. I lied. I concealed. I avoided everyone and everything who might figure it out. I was supposed to be Carrie the Recovery Girl. How could a two-time ED book author relapse?

Um, the same way as anyone else.

Though there is still embarrassment and shame, it is SO MUCH LESS now that everything is out in the open, and now that I realized the only one who ever thought I could never relapse or struggle EVER was, you know, me. I was putting my internal BS on all of you, and it is unbelievably gratifying to know that this was a figment of my imagination.

Relapse is a grim reality for eating disorders. Not inevitable, and not something I think should make you quiver with fear at all hours, but it's always possible. This is the nature of the illness. I've wasted enough time feeling sorry for myself and heaping on all the spoonfuls of self-hatred that I'm really going to try and stop at this point.

Thank you. It feels so trite and cliche, but seriously, thank you ALL.

There's no easy way to write this, no way to make it less awkward and embarrassing (and yes, even shameful) for me, so I'm going to plunge on ahead and get it over with.

I've relapsed.
Big time.

My parents are coming on Friday to move me back to that mitten state in the Midwest, though I probably won't leave DC until Monday.

This relapse struck hard and fast and caught me completely off guard. Things really just started deteriorating in the past 6 weeks--just when I got the boot off and didn't have my handy (or footy) excuse for eating properly and staying off my feet--and by the time I realized the waters of anorexia were reaching up to grab me, it was too late. I was already soaked.

Events would have eventually come to light. The weight loss is blatantly obvious- to others, of course, not to me. I see the same scrubby redhead that I usually see. But during my therapy session last night, I got overwhelmed with guilt and grief and confusing and 'fessed up. I am profoundly grateful I have the best therapist in the world (no exaggeration), that my parents are willing to feed me again, after I ruined things, again. I am grateful I have so many people cheering for me, like Laura and others who read my blog.

But right now, I'm only feeling this gratitude in my head. My heart is full of shame and anger and resentment at Life, The Universe, and Everything and also, you know, me. I do understand that my eating disorder isn't my fault, but I also feel I should have known better. I was not so arrogant as to think that I could never relapse, that this couldn't happen to me. I knew. I knew, perhaps, too well. In the end, though, that's neither here nor there. I can't go back in time. I can't wave a magic wand and make this relapse go away as if it had never happened. Nor should I. I'm pretty much the opposite of a fatalist- I don't usually believe that "things happen for a reason." But I am an advocate of learning as much as you can from your life experiences.

I'm not going to waste energy that I don't have right now trying to understand what went wrong. I get the basics for now, and that's enough. I got really depressed and I let my defenses down. I became too depressed and too defeated-feeling to push myself to eat what I needed to, and so the passive restricting started. I wasn't seeking to lose weight. I wasn't trying to fuck myself and my life over one more time for old times' sake. Something threw my brain into anorexic mode, full steam ahead, and that was the end of that.

So I'm going home, back to the magic plate and refeeding and all of the crap I thought I had washed my hands of. I will wash my hands of them again. It will take time, lots of time, and patience and food and love. I have to believe that, however improbable it may seem to my malnourished brain at the moment.

But my blog isn't going anywhere. It's been my sanity lifeline.

ED behaviors are obviously way more than just a bad habit, but they can be habit-forming. I buy a certain brand of cereal because that's simply what I buy (and choosing a new brand is complicated, plus I like this cereal). I exercise at 8pm because that's just what I do.* Or the weighing rituals I used to have. Though ED-driven, they are still habits. I do them almost without thinking.

Of course, humans are creatures of habits and we all have these things we do without thinking. If we had to think about every little thing we did, we would never be able to process all of the information we needed in order to survive. Habits can be useful.

And new research shows that although we can break old habits, we never forget them. (h/t Lola via Twitter)

"There's an expenditure of energy involved in changing behavior," says Dr. Nora Volkow, director of the National Institute on Drug Abuse in Bethesda, Md. "That's where motivation comes in."

Scientists theorize that in acquiring a habit, be it good, bad or innocuous, you typically start out with "goal-directed behavior," meaning you perform a certain action in a certain situation because you expect to reach a certain goal. But if you repeat this same action in this same situation over and over, you get to the point where you take a particular action in a particular situation simply because you're in that situation. Your goal has dropped out of the equation.

The findings [from animal studies] also show that once you have a habit, you may break it -- but you don't forget it, says Graybiel, senior author of the study. "The minute you put the reward back, it's back."

Which helps explain why avoiding relapse in eating disorders can be so difficult. In our diet-centric culture, we are literally bathed in the triggers that set off our ED habits, and the "rewards" of these behaviors (eternal happiness! less anxiety! weight loss! perfection!) are thrown in our faces. These cues can take our brains back to ED central and recovery can be literally flushed down the toilet.

I don't know how to peacefully live with all of this. I ignore it as much as possible, but I'd have to be a modern day hermit to avoid it entirely. There's something to be said for learning to see through the garbage, of understanding that people want to make a quick buck and that every diet ad is essentially bogus.

Our brains are built to overvalue the rewards we can get right away and undervalue those we might only receive later. Similarly, we tend to avoid any small unpleasantness we'd have to face now even if we know it may mean bigger difficulties down the road.

So if ED behaviors are the immediate reward our brains crave, what are we to do?

Three words: develop new habits.

I may never not get a starvation high when I stop eating, so I need to find really good reasons to keep eating. I need to get new habits (waking up 10-15 minutes earlier to eat a proper breakfast, taking rest days from exercise) to replace the old ones. It's hard, when ED served its purpose so well, and those rewards will never disappear, not entirely. But good things exist outside of the monotony of the eating disorder, rewards that give life rather than take it away.

*Well, not since I got The Boot.

This winter has not been easy on me- I have been hanging in there by the skin of my teeth. Around November or so, the amount of exercise I was doing began to creep up...and up and up. Yet it took until the middle of this month for me to realize that things were really out of control. My weight had dropped some, nothing catastrophic, but also nothing to sneeze at. I have managed to get back on track with the exercise and eating, in part due to a painful left foot.

For the past month or so, I have had this nagging foot pain that wasn't getting any better. I got a referral to the podiatrist about two weeks ago, and finally got in for an appointment this morning. He took one look at my foot, poked at a spot he said "looked puffy" (I couldn't really tell the difference), poked it causing me to yelp, and said, "Yep- that's a stress fracture." X-rays confirmed the diagnosis.*

What does this mean for Carrie? No exercise--none--for about three weeks, and then only non-weight-bearing things like swimming or a stationary bike. I also have some fun footwear in the form of a walking cast, aka The Boot. Otherwise, rest, Advil, and ice, with orders to come back for more x-rays in about a month.

Well, shit.

A metatarsal stress fracture is pretty classic of the female athlete triad, the combination of osteoporosis, disordered eating, and amenorrhea. Although I currently get a period, I do have a history of osteoporosis/osteopenia (depends on the bone- my spine is the worst), and the disordered eating--well, you knew that. It's not that I think I'm invincible. I've experienced too many things to really believe that. But I didn't think the ED would keep affecting me, even after being in recovery.

And the more I think about it, the more I realize exactly how driven and disordered my behavior was. I was exercising several hours a day on a fractured foot. This sort of behavior is light-years away from wanting to look like the ingenue of the week or getting some sort of revenge at Mommy Dearest for not letting me go on Spring Break in high school. This sort of behavior is tremendously biologically driven and very addictive in nature.

I'm kicking myself (with my good foot) for letting the exercise get out of hand. I feel I should have known better. Although I've had exercise issues in the past, they never approached many of the stories I would hear in treatment. My behavior was compulsive, although not phenomenally excessive. This time around, however, it was both.

I want to forget, I really want to forget, how much ED lurks and may always lurk. I want to think there will be a day when I can relax and be a little less vigilant. But for now, I have to remember that Mad-Eye Moody said it best: The price of freedom is eternal vigilance.

*It's not uncommon for stress fractures in the foot to fail to appear on an x-ray, but sometimes they do.

This is a subject I'm rather interested in: long-term recovery. Much of the research on recovery focuses on the acute phase of treatment--and, to some extent, rightly so. If you can't start getting better, than figuring out how to stay better is somewhat secondary. Except there are a lot of people who have crawled their way out of the hellhole of the eating disorder and are now focusing on staying well.

So what do we know about how to stay well from an eating disorder?

Answer: not a whole lot. Continuing nutrition, obviously. Management of co-occurring mental and physical disorders. Therapy as needed.

But these are all very vague things. Everyone is different, and so getting too prescribed in terms of treatment isn't super useful, either.

However, a group out of the University of Iowa and Harvard University followed women with AN or BN for 10 years, and found that "worse psychosocial function and overconcern with weight or shape demonstrated statistical significance in increasing the risk of relapse." The researchers found that approximately one-third of women whose eating disorders had gone into remission ultimately relapsed, and rates were the same regardless of initial diagnosis. And regardless of whether the person presented with the restricting subtype of anorexia, the binge/purge subtype of anorexia, or bulimia nervosa, most people relapsed into binge/purge behaviors.

Several interesting points:

• the researchers defined remission as "having a period of 8 consecutive weeks in which no or minimal symptoms of the syndrome were present," which doesn't seem like a super long time to define something as ephemeral as 'recovery' or 'remission.' Then again, that also would seem to imply a relative freedom from body image issues and other ED thoughts, which is pretty indicative of significant progress towards recovery.
only ONE THIRD of the women presenting with a diagnosis of anorexia nervosa even achieved an eight week period of remission. If that doesn't signal the need for better treatments, I don't know what does.

The authors say that

Women with poor psychosocial function may be less equipped to cope with life stressors. Thus, stress coupled with poor coping may lead to a return of symptomatic behaviors...In addition, poor psychosocial function among recovered patients may contribute to the emergence of such stressors. Such a pattern may explain why interpersonal psychotherapy has demonstrated efficacy in the treatment of bulimia nervosa at follow-up.

As a solution, the authors say that "Thus, the combination of poor psychosocial function and increased concern about weight and shape may trigger the return of full eating disorders. Teaching patients to cope effectively with psychosocial stressors and to accept their bodies may help prevent relapse into eating disorders."

It's an older study (from 2005), but it does provide some useful information on an area that's not well-researched. If only the authors hadn't thrown that "food is something sufferers can control..." stuff into the last paragraph. Oh well.