ED Bites

Midlife eating disorders

2009-07-13T20:21:00.002-05:00

Midlife eating disorders are being increasingly discussed both in the research literature, amongst clinicians, and in the popular press. Today, the New York Times ran a piece on the subject that raised many of the issues facing both sufferers and clinicians.

Most clinicians are in agreement that they are seeing more and more older women with eating disorders. I don't doubt this, although it should be said that we don't have hard data on whether that means more older women are suffering from eating disorders or that more older women are presenting for treatment. Several treatment centers (including the Cambridge ED Center and Renfrew) have programming specifically geared towards older women and addressing the issues specific to this age group. Which is a really good thing as many of the practical, day-to-day coping needs of adolescents and older women are probably going to be different.

A study comparing female inpatients aged 40+ and those aged 18-25 found that the older women showed

"significantly more diagnoses of anorexia nervosa, both subtypes, and fewer diagnoses of bulimia nervosa; greater ED severity but fewer body image issues and less body image distortion; greater emotional and behavioral overcontrol and symptom denial; more bipolar and major depressive disorders, suicidality, and sexual abuse histories; a trend toward greater misuse of calming/sedating substances; and fewer maturation issues."

The real question is: why the uptick? Why is it that more and more older women are being diagnosed with eating disorders? Could it be improved awareness, that starving, bingeing and purging aren't just "teen things"? That people are talking about it now? Could we be seeing an uptick from several decades ago and they have relapsed or never recovered?

For women in their 40s and over (which the Times article seemed to focus on) who seek treatment for an eating disorder, there are essentially three scenarios: the ED began in midlife, the woman has been chronically ill since adolescence/young adulthood, and the woman had previously recovered from an ED but has since relapsed. Research suggests that the first scenario is pretty uncommon, as one study found no evidence for midlife-onset EDs, though it did survey a small number of women. Other studies, however, have looked at women reporting midlife onset and found that women whose ED began after age 40 were more likely to be anorexic, and showed higher symptoms of denial.

Clinical anecdote, however, does seem to indicate that EDs in most midlife women began in adolescence and young adulthood. This goes along with the NEDA statistic that 86% of ED sufferers report illness onset prior to age 20. No one knows exactly why most EDs are triggered in adolescence, but changes in both hormones and social milieu seem to combine in a very bad way. Another factor is that, in modern, Western culture, almost no woman can pass the age of 20 without having gone on a diet, gotten a stomach bug, or otherwise eating poorly for a period of time. It's pretty darn hard. I had spoken with Harriet Brown during her search for women whose EDs began after 25, and she said she really couldn't find anyone who didn't at least have a sub-clinical disorder in adolescence.

I have much sympathy for the struggle to maintain recovery throughout a lifetime--it's something I'm currently striving for, if occasionally sucking at. Relapse happens. It's a grim reality, and midlife does bring on a host of new stresses that can cause a person to deliberately or inadvertently alter their eating habits.

I have just as much sympathy and empathy for those who have struggled constantly since adolescence. I have a little less sympathy for our long, gloried history of ineffective treatments, but I still wonder. The NYT article said that "the recent surge in older women at eating disorder clinics is not a reflection of failed treatment, experts say, but rather a signal that these disorders may crop up at any age."

It's true that EDs can crop up at any age, but the evidence doesn't support that this is true for the vast majority of midlife eating disorders. Most of them have roots in adolescence. And I can't help but wonder whether we would be seeing these numbers if there were effective treatments around 20 years ago.

EDs are mental illnesses

2009-07-12T22:42:00.003-05:00

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.

What causes an eating disorder?

2009-07-11T22:04:00.002-05:00

This is pretty much the $64,000 question in the ED world right now. It sounds kind of silly, but the question remains: what causes eating disorders? And the truth is, we don't know. We know what doesn't cause eating disorders, which includes skinny supermodels, bad parenting, and control issues. Do they contribute? Absolutely. But that's different from cause.

I've contemplated this issue for years and have blathered on and on about it in this blog. Yet these several paragraphs from the Around the Dinner Table forum in response to the question "Are EDs a control issue or a chemical imbalance?" by my dear friend IrishUp says it so succinctly and so right on, that I had to share. I could not improve upon this explanation no matter how hard I tried.

There are two distinct issues being conflated in this statement; A) What is the etiology, or natural history, of ED? and B) What is the internal experience of someone who has ED? The former deals with the brain, our most important organ. While our understanding of the brain is in its infancy, the BRAIN is without a doubt a physical, tangible object and we can describe brain structure and function with the languages of science and medicine. The latter has to do with the MIND, and that is a much more elusive thing. It's not tangible. It's mostly subjective. The nature of the mind is best described in the languages of philosophy and theology. And yet, our MIND is a function of the BRAIN. So we've developed the discipline of Psychology to bridge the gap between the tangible and intangible, the objective and subjective, science and philosophy and theology.

Eating disorders are the behavioral expressions of bio-chemical and neurological disorders of the brain. People who exhibit EDs were born with genetic traits that made them susceptible to developing the disorders if and when certain kinds of experiences occur in their environment. The genetics seem to express themselves as high levels of anxiety/social anxiety, OCD, perfectionism, conflict avoidance, and other related traits long before ED occurs. Common environmental triggers include conscious diets, strep infections, trauma or high stress, and incidental periods of insufficient caloric intake (like the kid undergoing a growth spurt, or the athlete whose training intensifies). It looks like, by and large, you need at least one ingredient from each the "nature" and the "nurture" columns to develop ED, and most people have more than one from each. Additionally, the developmental changes the brain undergoes during adolescence seems to play a key role, as the vast majority of EDs exhibit themselves at this stage. Since our social milieu also changes radically during this time, it is likely that the environmental triggers are stronger and/or more common at this stage.

Given the above, someone who has ED may well experience it as "a control issue". In fact, many ED sufferers report that they have (short lived) positive "control" thoughts when they don't eat, and negative "control" thoughts when they do. They also have a tendency to misinterpret other's actions as negative. And to think thier own bodies as larger and shaped differently from how they actually are. But these thoughts are actually a symptom of the disease. This is similar to how people with the classic symptoms of schizophrenia (hearing voices, believing outside forces are controlling their actions, & etc) are having the symptoms because of the neurological imbalances of that disease. In both cases, the person is having real experiences inside their mind that have little to do with the outside environment.

And different still from the physical causes of a disease, or the mental symptoms the disease may cause in our thinking or our understanding while we are sick, is the MEANING we attach to things we experience. Our experience of "what does this all mean?" is ultimately completely subjective, and completely dependent on our belief systems. If we beleive diseases are caused by voodoo curses, or cold unloving mothers, or imperfect faith, or a kind of test from a higher power, or none of the above, or all of the above, our understanding of the disease experience will be framed in terms of that belief.

So if someone states "I got ED because I needed more independence from my father", he's not "wrong", he's just talking about how ED fits into a larger meaning in his life. It also shows that that person is not being exposed to good clinicians who could tell him "Well, yes, you may have needed more independence. However, if you hadn't had the genetic makeup you do, the stress of the situation would not have triggered the development of ED."

Maybe, then, the answer to this cogent question--are EDs culturally-based or biologically-based--is BOTH.

Eating gives me a headache

2009-07-10T11:05:00.006-05:00

Eating can be a pain- I know this very well. There's the I'm-writing-and-in-the-groove-and-don't-want-to-stop part that I think most writers know well. Then there's the I-have-an-ED-and-eating-SUCKS part that I think most people with eating disorders know well.

Thankfully, Tylenol has a cure for this.

That's right- who needs food when there's Tylenol? Because eating regular meals is, I dunno, so last year. If white is the new black, then is Tylenol the new food? I just need to ask my dietitian whether Tylenol is a grain or a vegetable...

Thanks (I think) to AS for posting this on Facebook.

Curing hypotension, one letter at a time

2009-07-09T16:20:00.002-05:00

Low blood pressure and orthostatic hypotension (a massive drop in your blood pressure when you go from sitting to standing) frequently accompany eating disorders, and I am no exception to this. A recent letter my dad received from our health insurance company provided such a fantastic cure that I had to share it here:

Step One: Get initial blood pressure reading.

Step Two: Read first paragraph.
"As a valued customer of [Health Insurance Company], we want to inform you of an exciting new contest. [Health Insurance Company] is committed to [this state's] health through our unique mission and believe in supporting healthy lifestyles. That's why we're proud to join forces with [local TV station] and The Parade Company for the Biggest Loser: [Big City] Edition.

Step Three: Repeatedly use four letter words and contemplate ripping letter into small shreds and igniting it on the grill when you make s'mores as part of your new anti-anorexia healthy lifestyle. Your face may turn red- this is a normal side effect of rising blood pressure and should be expected.

Step Four: Read second paragraph.
"The contest is simple. Anyone can enter at [website] by telling us their story and why they want to change their life through healthy weight loss. The deadline to enter is July 24. [Health Insurance Company] and [local TV station] will then select six contestants and track their progress towards a healthier future. One of the six contestants will go on to be named [state's] Biggest Loser, win some great prizes and ride on a float during America's Thanksgiving Parade."

Step Five: Feel face turn from red to crimson. Some veins may emerge, especially on the forehead and neck. Again, this is a normal side effect of increasing blood pressure.

Step Six: Read last paragraph.
"It's about eating well and exercising to lose weight, and [Health Insurance Company] is looking forward to helping people take the first step towards a healthier lifestyle. We encourage you to check out the contest details at [website] and spread the word to your employees."

Step Seven: Get another blood pressure reading. Higher? Congratulations! You've cured your low blood pressure. Now it's time for some matches.

Of course, I would like to send the health insurance company links to educated, informed opinions about the general ineffectiveness of dieting (yes, it's still a diet whether you call it a "lifestyle change" or a "contest") and of the health risks of the Biggest Loser in particular. I would love for them to read in detail about my own former workplace's Big Fat Loser contest and how I wound up quitting to save what little sanity remained after being inundated with posters tallying people's weight loss and signs saying "Nothing tastes as good as thin feels."

I would also really REALLY like this Health Insurance Company to know that there are many different aspects to a healthy lifestyle, such as, I don't know, not having an eating disorder. The jury is still out as to whether obesity significantly raises mortality risk; it's not for eating disorders. A girl with anorexia is ten times more likely to die in the following year than a classmate without anorexia. This is the same douchebag insurance company that refused to cover a DIME of my last residential treatment stay because they said it "wasn't medically necessary" or that the facility I went to wasn't in-network. It depends on which denial letter you read, but the results are still the same. Never mind, of course, that I was in and out of the ER several times a week with hypokalemia, was in ketosis, had irregular EKGs, and was underweight and still dropping rapidly.

Committed to healthy lifestyles, my anorexic ass. They're committed to paying out as little money as they possibly can, and they think that by supporting crash dieting, they will save money in the long run and look good in the short run.

Have I cured your low blood pressure, too? Writing this sure cured mine!

Failure of the medical system?

2009-07-08T11:08:00.003-05:00

I hesitated a bit to blog on this for a variety of reasons, the major ones being a) the death of Michael Jackson has been a wee bit over-publicized and b) I don't like gossip and accusations. However, the more I thought about it, the more I realized that what I had to say was less about the King of Pop and more about people with eating disorders in general.

To be honest, I don't know whether Michael Jackson had an eating disorder, or body dysmorphia, or addiction problems. Perhaps the final autopsy will have some of those answers, and perhaps we may never fully know what happened. But a recent editorial (working on the assumption that all three were true) said that the medical system had failed Michael Jackson.

Most people with eating disorders don't have the kind of fame and money that MJ had, but perhaps family and friends and medical professionals still fell sway to the same assumptions that MJ's doctors might have. MJ was dancing and rehearsing and performing- he couldn't be that bad. I had straight As and a research position and scholarships- I couldn't be that bad. This is, maybe, fame and fortune of a type. People held my academic and musical accomplishments in awe. Though I would be the first to dispute the accuracy of that, I will also admit that these achievements gave a lot of people plenty of reasons to overlook the oh-so-minor detail that I wasn't eating.

Writes Mark Rubi in his editorial:

Time and again, these pillars of American society reacted to a starving patient with prescription drugs.

I'm not anti-prescription drugs- just look in my medical cabinet and you'll see quite an array. And any toxicologist will tell you that the dose tends to kill you, much less than the drug itself. That being said, maybe what MJ needed was someone to say screw the fame, you need to eat. The medication he may have been most in need of was food. But people may have been afraid to say something because of the fame, afraid of what that might mean. Maybe some of my professors and supervisors were afraid of what my wasted frame might mean. Maybe they just didn't know. Or maybe they thought I could see the problem and would ultimately do something about it.

And that is the biggest failure of the medical system when it comes to eating disorders: that we expect people to want to get better and to do everything possible to recover. But in the acute stages of anorexia especially, the sufferer is almost unable to perceive his/her condition accurately. Either I truly didn't think I had a problem or I didn't think starving myself was problematic, or it wasn't that serious. I wasn't, like, emaciated or anything (except, oops, I was). If a high school valedictorian got cancer, we wouldn't wait for her to will herself well. But most medical professionals were quite content to do that when I developed anorexia.

Did the medical system fail MJ? Perhaps. But sadly, perhaps no worse than many other people with eating disorders have been failed.

Skeletons in the closet?

2009-07-07T20:54:00.000-05:00

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 "familyhistory is useful for determining patients' clinical prognosisand 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.

Why the BMI is Bogus

2009-07-06T20:31:00.002-05:00

I saw this link on Tiptoe's blog and let me just say: I love it, I love it, I love it!

This should be required reading for any health journalist who uses the letters "BMI" in a story--which is basically all of them.

In its entirety (because it's just that good) is the "Top 10 Reasons Why the BMI is Bogus":

1. The person who dreamed up the BMI said explicitly that it could not and should not be used to indicate the level of fatness in an individual.

The BMI was introduced in the early 19th century by a Belgian named Lambert Adolphe Jacques Quetelet. He was a mathematician, not a physician. He produced the formula to give a quick and easy way to measure the degree of obesity of the general population to assist the government in allocating resources. In other words, it is a 200-year-old hack.

2. It is scientifically nonsensical.

There is no physiological reason to square a person's height (Quetelet had to square the height to get a formula that matched the overall data. If you can't fix the data, rig the formula!). Moreover, it ignores waist size, which is a clear indicator of obesity level.

3. It is physiologically wrong.

It makes no allowance for the relative proportions of bone, muscle and fat in the body. But bone is denser than muscle and twice as dense as fat, so a person with strong bones, good muscle tone and low fat will have a high BMI. Thus, athletes and fit, health-conscious movie stars who work out a lot tend to find themselves classified as overweight or even obese.

4. It gets the logic wrong.

The CDC says on its Web site that "the BMI is a reliable indicator of body fatness for people." This is a fundamental error of logic. For example, if I tell you my birthday present is a bicycle, you can conclude that my present has wheels. That's correct logic. But it does not work the other way round. If I tell you my birthday present has wheels, you cannot conclude I got a bicycle. I could have received a car. Because of how Quetelet came up with it, if a person is fat or obese, he or she will have a high BMI. But as with my birthday present, it doesn't work the other way round. A high BMI does not mean an individual is even overweight, let alone obese. It could mean the person is fit and healthy, with very little fat.

5. It's bad statistics.

Because the majority of people today (and in Quetelet's time) lead fairly sedentary lives and are not particularly active, the formula tacitly assumes low muscle mass and high relative fat content. It applies moderately well when applied to such people because it was formulated by focusing on them. But it gives exactly the wrong answer for a large and significant section of the population, namely the lean, fit and healthy. Quetelet is also the person who came up with the idea of "the average man." That's a useful concept, but if you try to apply it to any one person, you come up with the absurdity of a person with 2.4 children. Averages measure entire populations and often don't apply to individuals.

6. It is lying by scientific authority.

Because the BMI is a single number between 1 and 100 (like a percentage) that comes from a mathematical formula, it carries an air of scientific authority. But it is mathematical snake oil.

7. It suggests there are distinct categories of underweight, ideal, overweight and obese, with sharp boundaries that hinge on a decimal place.

That's total nonsense.

8. It makes the more cynical members of society suspect that the medical insurance industry lobbies for the continued use of the BMI to keep their profits high.

Insurance companies sometimes charge higher premiums for people with a high BMI. Among such people are all those fit individuals with good bone and muscle and little fat, who will live long, healthy lives during which they will have to pay those greater premiums.

9. Continued reliance on the BMI means doctors don't feel the need to use one of the more scientifically sound methods that are available to measure obesity levels.

Those alternatives cost a little bit more, but they give far more reliable results.

10. It embarrasses the U.S.

It is embarrassing for one of the most scientifically, technologically and medicinally advanced nations in the world to base advice on how to prevent one of the leading causes of poor health and premature death (obesity) on a 200-year-old numerical hack developed by a mathematician who was not even an expert in what little was known about the human body back then.

Note: if you click on the story link, you can listen to the NPR segment as well.

One of these things is not like the other

2009-07-05T22:43:00.004-05:00

I am, yet again, brutally exhausted. I don't know where it's coming from (well, okay, I guess I kinda do), and it's annoying me to the nth degree. My body has taken quite a beating over this past decade, and I think the wear and tear is beginning to show. I'm not bouncing back like I used to. I often feel like I could sleep all day--not in the depressed asleep-is-MUCH-better-than-awake kind of way, but in the my-veins-are-seriously-filled-with-lead kind of way.

Maybe it's a psychosomatic thing, these feelings of heaviness. Could there be a relationship between exhaustion and feeling like I am detectable on radar? Or between tiring out at the slightest exertion and those feelings that I am generating a massive gravitational field? I don't know. I feel like I have gained back all of the weight I lost during this last relapse and then some, despite evidence to the contrary. I know I'm gaining weight, but I have nary a clue how much that is. My "skinny jeans" still fit, although they're a bit tighter. I know I couldn't get them on at my usual weight, so there's that.

But when I look in the mirror, it's all over with. I look in the mirror and I see someone chubby. Overweight. Someone who could use a three-hour-long kickboxing class to get her lazy ass in gear. Someone in the "before" weight loss pictures. It's what I see. It's reality- my reality, anyway. The real reality is that I have no freaking clue what size I am.

Here's a little secret that I'm not proud of: when I pass other women in the store or on the street, I want to try on their pants. Not because I care what size they are, but because I want to know what size I am. Does this make any sense? Some people, I know that I'm probably bigger (i.e., the kindergartner in pigtails) or probably smaller. Many times, I think I'm bigger than the "average" person I see walking down the street. Although I'm probably skewed in guessing other people's sizes, I know I'm a bit more accurate than when I look at my own reflection and just go "Ewwwwww!" If I can figure out what size I am compared to other people, maybe then I can get an idea of what size I actually am. Hence my undying need to try on other people's pants. I really have no idea. None. Whatsoever.

(EDITED: see Laura's great post on body schema and body image here)

This is understandably hard for other people to understand. I do okay with determining my height in relation to other people, though being of average height, that's not too difficult. But the rest of my body image is pretty much this nebulous haze of (what I perceive as) excess adipose tissue. I don't know that I would have understood this phenomenon if I hadn't lived it. I also realize that being afraid of food is something that's hard to understand unless you've been there. My mom joked once, a long time ago, that she could never be anorexic because she likes eating too much. But an anorexic is obsessed with food, in love with it, even. Just so long as she doesn't have to actually eat it.

I still don't like eating and I'm quite frankly tired of it. I'm sick of facing food six times each day, an endless parade of meal, snack, meal, snack, meal, snack. I cringe at the knowledge that I am getting bigger and fatter with every bite I take and that this is the only way out. I then get wondering whether out is better than in and the so-called Point of it All. I hate that the happy little routine I had going for myself has been rudely interrupted while everyone else's life gets to go on as usual.

I get that I have an eating disorder. I get that basically not eating and exercising compulsively for two months (two weeks, two days) is a Very Bad Idea. I knew that at the time, I just didn't care enough to stop. I get that what I see in the mirror and what other people see when they look at me are two completely different things. I understand this and I don't. I want these realities to match up.

Maybe this goes along with my ability to "see things differently"?

Sing it from the rooftops!

2009-07-04T11:46:00.002-05:00

To everyone who says that weight loss is the answer to "overweight" and "obesity," I recommend reading this research article:

Comparing the health burden of eating disordered behaviors and overweight in women

The researchers interviewed a community-based sample of Australian women to determine the effects of overweight and ED behaviors on quality of life, psychosocial functioning, and physical well-being. The researchers found that overweight led to increased physical problems but relatively little impairment in normal day-to-day functioning. However, those women with eating disorders showed some increases in physical problems but a large impairment in psychosocial functioning and quality of life.

Conclude the researchers:

Further, impairment in psychosocial functioning associated with eating-disordered behavior was greater than impairment in physical health functioning associated with overweight, and impairment in physical health functioning associated with eating-disordered behavior was greater than impairment in psychosocial functioning associated with overweight. Overweight and eating-disordered behavior were associated with similarly elevated rates of primary care consultations during the past 6 months and of lifetime treatment from a health professional for an eating or weight problem.

Conclusions: In young adult women, the health burden of eating-disordered behavior may be more substantial than previously recognized. Better information concerning the spectrum of disordered eating that exists at the population level needs to be made available. Eating-disordered behavior warrants greater attention when considering the public health burden of obesity and in developing programs to reduce this burden.

Even if overweight and obesity are associated with health problems, we don't know how to reliably get people to lose weight and keep it off. Furthermore, many extreme diet measures can very well be the beginnings of an eating disorder--or at least really unhealthy. And if "obesity prevention" results in higher rates of eating disorders, the "cure" may very well prove to be worse than the "disease."

Like mommy, like kitty

2009-07-02T22:40:00.002-05:00

My parents and I had to go out of town briefly, so I dropped Aria off at the vet's to board and have her surgery. As standoffish as she is, she also needs company. Even with a cat-sitter checking in on her once a day, she wound up meowing herself half hoarse while I was away for a long weekend for work.

But when Aria gets upset, Aria stops eating. She has green eyes like me, and her fur is remarkably similar in color to my hair. I know what I want (usually), and she always does. So there are many, many similarities between us, although this is a cat without self-esteem and body image issues. I know she's not trying to catch her reflection in the glass to see if her collar makes her butt look fat. I know she doesn't have an eating disorder.

That being said, she also nibbles at my mom's fake grass (it's "well mowed") and has decapitated her plastic daisies. One of her favorite things to lick is her butt, and she also snacks on various bugs and the cottonwood tree blossoms so prevalent in June near my house (we call 'em "fuzzies"). My therapist joked that the Fluffer Nutter might very well have pica. I don't know that Aria will cooperate with therapy, but then she doesn't really cooperate with much.

I know, however, that she will never struggle with exercise addiction like her mommy! Why? These two photos from I Can Has Cheezburger could have been written by her!

Yep- I think she'll turn out just fine. Keep your fingers crossed- she has her dental surgery tomorrow!

Great quote!

2009-07-02T22:26:00.002-05:00

I was out to dinner tonight at a fabulous restaurant, and I saw this quote above the door:

"All the change that needs to happen in America starts at the dinner table."
--Ronald Reagan

It really resonated with me because so much in my life that needs to change has to happen around the dinner table.

Dear journalists: please try harder

2009-06-30T16:59:00.004-05:00

I have much sympathy out there with journalists and reporters, seeing as I am one of them from time to time. Writing on deadline is difficult. Eating disorders are subjects that are fraught with meaning, are not well understood by most people, and are amazingly easy to inadvertently sensationalize. And it is the so-called "meaning" of eating disorders that has me the most tweaked about two stories that I read about today.

One, from CBS titled "Tweens Starving for Perfection," had me annoyed from the title. An eating disorder is NOT ABOUT starving for perfection! It passes along the subtle but absolutely incorrect idea that starving or losing weight will make you perfect--or at least "better." Second of all, I understand very well that an eating disorder can take on meaning in the context of our individual lives. My own experiences have meaning, and so do everyone's, eating disordered or not. But my symptoms (starving, purging, over-exercising) weren't meaningful. They were the result of an illness, not a conscious desire to look better.

I see exactly where people get confused. Hell, I was confused and mired in a cesspool of potential meaning and uninterpreted histories for several years. It was only when I was told, over and over like Robin Williams did to Matt Damon in "Good Will Hunting," that anorexia was a brain disease and these actions were symptoms of an illness. They weren't me trying to express myself on a subconscious level- the only thing they meant was that I had an eating disorder.

Only, humans like to explain things. Think of how many creation stories out there address the question of "Who are we and where did we come from?" Eating disorders are baffling illnesses, both to loved ones and to the sufferer. When I was freaked out by my OCD symptoms in high school, I thought I was being punished for some unknown transgression by the Big Guy in the Sky. It was the only way I could make sense of it. As I went looking for an explanation for my intense fear of food, some of these ideas like "control" and "perfection" made a lot of sense. I freely admit I like to control my world and anyone who has ever met me can attest to my perfectionism. It did kind of make sense.

But my OCD wasn't punishment for a sin, and my anorexic symptoms were largely meaningless. Finding meaning doesn't bring recovery. Finding meaning may be psychically helpful, but I've found it largely useless in getting better. Incorporating your experience into your life story, weaving them into your own personal narrative and giving that some meaning- this is useful. Tremendously so, as I have done it and continue to do it. But that's not the same as saying I was starving for perfection. I was starving because I had anorexia, period.

Many of my complaints about the CBS story can be echoed with respect to this story from ParentsCanada called "Dying to Fit In: Do you know what your tween is not eating?" Schizophrenia is not dying to hear more voices, and depression isn't dying to be sad. Diabetes isn't dying for higher blood sugar, and cancer isn't dying for a larger tumor. An anorexic isn't starving for perfection and they're not dying to fit in. They're just starving and dying. And the sooner we can strip away this false meaning, the better we can get aggressive treatment and nutrition for the people who need it the most.

Raising awareness of eating disorders, especially in age groups where you might not be actively looking for them, is good. But please, try just a little harder. Please. It matters.

(Also see Laura Collins' excellent analysis of the CBS story here)

Cat food and other lessons

2009-06-29T22:26:00.002-05:00

I took Aria to the vet this morning, which requires a PhD-level subterfuge to corral her into her carrier. I brought the carrier up from the basement last night so that when she saw it and freaked out, there would be plenty of time for her calm back down. Then this morning, I thought I had closed all of the doors to Aria's favorite hiding places so that if she made a run for it, I could retrieve her with relative ease. She did end up under my bed, and secured herself to the carpet in a move that could be summarized as "Attack of the Velcro Kitty." Since neither treats, toys, tuna, or catnip can lure her out in this state, I wedged myself under the bed and gently "persuaded" her claws to transfer their death grip from the carpet to my arm. In she went, and I drove off to the vet's with a frustrated feline yowling in a sonorous baritone that probably would have gained her acceptance into the Mormon Tabernacle Choir.

The poor dear has a cavity in one of her teeth and is going back on Wednesday to have it pulled. She got two vaccines--on in each butt cheek--so Aria has a sore hiney. The vet asked me what Aria ate every day, the brand of wet and dry food, her treats, and how much she eats of each. Aria had gained a little weight in the past year, although I had to up her steroid dose with my move back to the Midwest as it amped up her dermatitis which no doubt caused some of it. The vet gave me some suggestions about her food intake that would help keep Her Royal Fuzziness at optimum health.

Instead of feeding her mainly dry food and supplementing with wet food, she told me to try the other way around (i.e., feed mainly the wet food and only a little bit of the dry, plus the treats she can weasel out of my dad with profound ease). None of this struck me as so interesting that I needed to blog about it. However, what the vet said next was what really lodged itself in my brain.

Wet food is higher-calorie the dry food, so it sounds kind of counter-intuitive that cats will better regulate their weight on higher-calorie wet food. But the wet food is high fat and high protein, while the dry food has a higher percentage of carbs. Cats don't usually eat much in the way of carbohydrates when they're in the wild, so they better metabolise the fats and the proteins and stay healthier.

The geeky side of the crazy cat lady in me thought of this study looking at the relationship between anorexia recovery and dietary energy density and variety. The study found what my fantabulous dietitian has been telling me all these years: eat a wide variety of foods and make sure you eat enough protein and fat!! Like Tina's wonderful experiment, adequate fat and protein intake is important for humans and cats alike.

I worry a lot about feeding Aria because I don't want to project my own food issues onto her, or go completely in the other direction because I fear the thought of someone going without food. It has made me much more sympathetic towards the issues mothers with eating issues (past or present) face in feeding their children. I know that right now, I'm not good at judging how much I need to be eating. I leave that to my dietitian and my parents because, like I said, I don't know. So if I'm not confident in feeding myself, how can I be confident in feeding my (fur)child? Which is why I think research like Nurture at UNC Chapel Hill's ED Program is so important. Hopefully it will give women the knowledge and confidence they need to make good decisions for themselves and their children.

Besides my copious packages of Ensure Plus that I pick up at the grocery store now, I guess I'll have to add some more tuna for Aria.

This is your brain on anorexia

2009-06-28T23:11:00.004-05:00

My brain feels like mush. The cognitive affects of my ED are some of the most annoying for me to face. The physical stuff, I can usually manage. But not being able to think straight, or to read and feel the text somehow evaporate in the short distance between my eyes and my brain--this drives me nuts. Even the simplest of tasks, whether it's brushing my teeth or crocheting, leaves me feeling like this little guy here:

So what do you think a complete geek like me does when she gets frustrated and exhausted? That's right- she turns to PubMed.

I found this study on the reversal of cognitive markers of anorexia with weight restoration rather fascinating for both my current state of mind and current state of body. Granted, the authors studied adolescents on their first presentation for AN treatment, neither of which are true for me anymore. That being said, I'm not entirely sure that these reversals would have been different for longer-term patients, although they may have taken longer.

Like Ancel Keys found in the Minnesota Starvation Study, adolescents in the acute phase of AN showed slower sensorimotor responses to stimuli and were more affected by others' interference. Working memory, however, was not impaired. After weight restoration, the adolescents' performance on the first two tasks were significantly improved, and "relative to controls, they were significantly faster on attention and executive function tasks, exhibited superior verbal fluency, working memory, and a significantly superior ability to inhibit well-learnt responses."

So although eating right now is making me want to bash my head in (metaphorically speaking- my head is pretty darn hard and I would fear more for the wall than my skull), one of the advantages to eating is the reassurance that my brain will work better. If only I could get an off switch for the silly thing...

What helps you along in recovery? It doesn't need to be existential or even particularly significant, just what you cling to when the going gets tough.

Honor your body

2009-06-27T11:10:00.002-05:00

My new friend Krystal emailed these spectacular words of wisdom to me yesterday, and it was so lovely I had to share it with you:

“You will receive a body. You may like it or hate it, but it will be yours for the entire period this time around.”

Every time someone says to me, "I'll give you 10 of mine" (when I say I want to gain), every time you are saying to yourself "I look like a boy," every time you feel weak for having wrinkles, or hips...know this: you are enough....you ARE your body. It's not yours to possess and whip into shape or manage. It is beautiful and broken and the only thing that in the world that does not leave you.

Honor it...don't just accept it. Honor it.

Can I just say?

2009-06-25T22:45:00.002-05:00

This sucks. I mean, this really really sucks.

I hate that I have to eat (and eat A LOT!) when I don't want to.

I hate that I hardly leave the house.

I hate that all I want to do is go for a run (yes, I have exercise issues and also see previous) and I'm not allowed.

I hate that I'm home from my job and my friends in DC and stuck in the Midwest.

I hate that I'm nearly 30 and have trouble feeding myself properly.

I hate that everyone watches me while I eat so I don't hide food.

I hate that people monitor my bathroom visits.

I hate that I eat six times a day and it seems all I do is eat.

I hate that I'm more obsessed with food now than I was before I started eating again.

I hate that I can feel my body doubling in size at every meal or snack.

I hate that I hardly have any privacy.

I hate that I'm such a burden on my family.

I hate that I have to face food every single day for the rest of my life and I'd really rather not, at least not unless it was apples and lettuce and nothing else.

But you know what I really really hate?

Knowing that this is necessary.

Knowing that I would go right back to the AN if given half a chance.

Knowing that yes, I am almost 30, and no, I haven't learned how to feed myself properly.

Knowing that the only way out is through.

(Sorry if this sounds like adolescent melodrama- I'm not going off the deep end, just deeply frustrated and a little pissed off at everything right now.)

‘Phantom fat' and body image

2009-06-24T23:01:00.001-05:00

I stumbled across a news article about how 'Phantom fat' can linger after weight loss when I was on Twitter (do you follow me on Twitter? Click here to start following ED Bites!) and I was struck by how much this seemed to describe what was going on in eating disorders. The article quoted a women who had lost a significant amount of weight over the past two years, and how

every morning when she looks in the mirror while getting ready for the day, she sees her former, heavier self. “My brain says, ‘Yep, still fat.’”

“It's been really hard to change my self-image,” says Hicks, 37, of Chesapeake, Va. “I still feel like I'm this enormous person who takes up tons of space.”

When I was in residential treatment the last time (in 2006), I groused about how fat I felt, how skinny all the other girls were, etc, etc. Standard AN kvetching and bitching. Still, the dietitian I was talking to made a good point: I had gained weight. Okay, not much, but I had, and I knew it and that's in part what I was there to do. My body was heavier than it had been. And considering I had been underweight for at least a solid year by the time I started treatment again (though my lowest weight was back in 2001), some of my physical feelings of fatness were not strictly ED-driven, but also might happen to anyone gaining weight. Or, in the context of the article, people losing weight as well.

I was oddly reminded of this conversation about a year ago, when I was riding the commuter train from DC to Baltimore, as I headed home from my summer internship. There was a 16-year-old boy (I'm guessing) and his family, and he was almost literally all limbs. He carried himself a bit awkwardly and--here's the really interesting bit--he kept banging his head against the overhead rack. He made a joke about his growth spurt, and it hit me: his perception of his body (known formally as proprioception) hadn't yet caught up with his new height! Cammy did a wonderful post about something similar right after this happened, which kind of cemented the incident in my head.

It makes sense that there would be a link between body image and proprioception, and researchers have found previously that the body image distortions in people with anorexia was linked to abnormal amygdala functioning and the fear response. So it makes sense that significant fluctuations in weight would be linked to both body image and proprioception, especially in people with a history of dieting like many of the women featured in the article.

“People who were formerly overweight often still carry that internal image, perception, with them,” says Elayne Daniels, a psychologist in Canton, Mass., who specializes in body-image issues. “They literally feel as if they’re in a large body still.”

Daniels and other experts suspect this may happen because the brain hasn’t “caught up” with the new, leaner body, particularly for people who were obese for many years and then experienced rapid weight loss.

“Body image is a lot harder to change than the actual physical body is,” Daniels says.

Amen to that, sister.

Psychologist Joshua Hrabosky found that women who were currently "overweight" or formerly "overweight" had a "dysfunctional appearance investment" and were more preccupied with weight that women who were never "overweight."

The findings suggest that “people who undergo major weight loss may experience improvements in satisfaction in appearance, though still not necessarily as much as someone who was never overweight,” Hrabosky explains. “But they are also still more invested or preoccupied with appearance than someone who was never overweight.”

It does make me wonder what dieting and food intake might have to do with weight perception and body image, as even healthy men in the Minnesota Starvation Study complained of "feeling fat" during the rehabilitation phase.

But the article raises some really good points about the psychology, too. When you've thought of yourself as fat for most of your life, it's really hard to change that thinking no matter how much weight you've lost or how much you understand the futility of dieting. I'm curious to see how this research will affect thinking on the body image distortions in eating disorders. We shall see.

Depression, anxiety, eating disorders, and culture

2009-06-23T22:08:00.003-05:00

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.

Emotions in anorexia

2009-06-22T20:59:00.002-05:00

Here's a bit of a confession: I have a hard time believing people like me. Why? There are the obvious self-esteem issues, but there's also my whacked-out interpretations of what other people must be thinking about me. When I'm talking, are they bored or do they just have a really full bladder? Is it a bad day or something I said? Are they offended or just not amused? Are they mad at me? Are they? Are they?

I usually conclude yes, they are mad at me, and then go about wracking my brain to determine what I did that could have caused them to hate me (note that being mad at me automatically translates into "you hate me" which is a cognitive distortion in and of itself). When I can't find anything, I assume it's just, well, me.

As I interact with people, I tend to hyper-interpret everything. An arched eyebrow becomes a stiletto through the heart. The flick of a wrist can toss cold water down my back. This isn't to say that I'm always right--nor that I'm always wrong, seeing as I've pissed off a few people in my time--just that I'm always aware, always looking for meaning.

So when I first read of the similarities between anorexia and autism, I arched an eyebrow of my own. My cousin's son is autistic, and though behavioral therapies have made a world of difference, he still has problems understanding other people's emotions, even just understanding that other people have emotions. Clearly, I didn't have this problem. I was almost too aware of what others might be thinking and feeling.

But the more I think about it, the more I realize that they are just (oh dear) mirror images of each other. Both my second cousin and I have difficulties in recognizing emotion. Whereas he doesn't interpret enough, I seem to interpret too much. And this issue only becomes worse when I'm malnourished and starving.

Previous research had shown that women with anorexia had difficulties in interpreting emotional faces. A recent study by Janet Treasure and colleagues found that women hospitalized for anorexia had difficulties in both recognizing and regulating emotions. The authors concluded that although they don't know whether this is a side effect of starvation,

the acceptability of emotions and recognition of emotions are important factors, so specifically practising emotion recognition and examining the function of emotions might be useful treatment targets. Building skills in emotion functioning may enable the client to feel more confident about social interaction and reduce isolation. It might also be useful to involve the family to build a shared understanding of emotional functioning.

The fantastic complexity of biology

2009-06-21T22:05:00.002-05:00

It's not a secret that I love science and in particular, biology. I majored in biochemistry in college and have a master's in epidemiology and infectious disease. I have been reading "Microcosm: E. coli and the new science of life" by Carl Zimmer, and so I didn't expect to run across anything that reminded me of eating disorders.

But if there's one thing I love as much as biology, it's metaphors. Or, in this case, finding parallels and expectations in the most unusual of places.

Many of the complaints I've heard about the importance of biology in eating disorders has less to do about the evidence and more to do with the simple fact that people think it's deterministic and depressing. If it's biology, there's nothing we can do. We were destined to become ill, and we're always going to BE ill because it's in our genes. To me, however, biology gives me a road map out of my illness, however vague and imprecise it is (think Columbus and Magellan, not GPS). I can't escape my biology, but I can learn to live with it.

Another complaint is that if eating disorders are genetically-based, then why don't all members of a family have them. Because not everyone's genes will be turned on at the right time to create a disorder. Environment matters, and it matters a lot.

Which is where one of my latest reads comes in. The actual passage is a little long, but I've tried to edit out the parts that didn't add to the ultimate point I'm trying to make.

We are not merely the output of software written in a programming code of DNA. As we develop in the womb, our genes interact with signals from our mothers. The environment continues to influence those genes in unpredictable ways after birth. The food we eat, the air we breathe, the traumas and joys and boredom of childhood, and all the rest have an influence on which genes become active...

Surely E. coli must be all nature and no nurture. A colony descended from a single ancestor is just a billion genetically identical cousins, their behavior all run through the same genetic circuits. E. coli is just a single cell, after all, not a body made of a trillion cells that take years to develop. E. coli doesn't grow up going to private school or searching for food on a garbage dump. It doesn't wonder whether it might like snails for dinner. It's just a bag of molecules. If it is genetically identical to another E. coli, then the two of them will live identical lives.

This may all sound plausible, but it is far from the truth. A colony of genetically identical E. coli is, in fact, a mob of individuals. Under identical conditions, they will behave in different ways...

There's much to be learned about E. coli by thinking of it as a machine with circuitry that follows the fundamental rules of engineering. But only up to a point. Two Boeing 777s that are in equally good working order should behave in precisely the same way. Yet if they were like E. coli, one might turn south when the other turned north.

The difference between E. coli and the planes lies in the stuff from which they are made. Unlike wires and transistors, E. coli's molecules are floppy, twitchy, and unpredictable. They work in fits and starts. In a plane, electrons stream in a steady flow through its circuits, but the molecules in E. coli jostle and wander...[This jostling] can produce long-term differences between genetically identical bacteria...Two genetically identical E. coli can respond differently to the same level of lactose because they have different histories...

At the very least, E. coli's individuality should be a warning to those who would put human nature down to any sort of simple genetic determinism. Living things are more than just programs run by genetic software. Even in minuscule microbes, the same genes and the same genetic network can lead to different fates.

Considering that I spent several years studying E. coli in college, I find these things fascinating. If we consider something like bacteria to be "simple," or at least simpler, with significantly fewer genes and much smaller than even a single one of our cells, and they are markedly affected by their environments, imagine how the environment acts on us. In biology, nothing is simple and easy.

More on the biological basis of eating disorders

2009-06-19T20:10:00.004-05:00

Most of my readers know by now that I don't dispute the fact that eating disorders are biologically-based mental illnesses. They clearly have a biological component, although this isn't entirely without controversy. Research has yet to tease out exactly what these components are and how they interact with both each other and with the world at large. But the latest science points to a strong biological basis for eating disorders.

I recently read a fantastic review article by none other than my "homeboy" Walter Kaye* called The Neurobiology of Anorexia and Bulimia Nervosa, the full text of which is now freely available, understandable, and well worth the read. A few lines that lodged in my head:

Because AN and BN present most often during adolescence in women, they are often theorized to be caused by cultural pressures for thinness since dieting and the pursuit of thinness are common in industrialized countries. Still, AN and BN affect only an estimated 0.3% to 0.7% and 1.5% to 2.5%, respectively, of females in the general population. This disparity between the high prevalence of pressures for thinness and the low prevalence of eating disorders (EDs), combined with clear evidence of AN occurring at least several centuries ago, the stereotypic presentation, substantial heritability, and developmentally specific age-of-onset distribution, underscores the possibility of contributing biological vulnerabilities...Twin studies of AN and BN suggest there is approximately a 50 to 80% genetic contribution to liability accounted for by additive genetic factors. These heritability estimates are similar to those found in schizophrenia and bipolar disorder, suggesting that AN and BN may be as genetically-influenced as disorders traditionally viewed as biological in nature.

Additive genetic factors are pretty much what they sound like: several independent genes that together influence the likelihood of developing an eating disorder. The more factors, the higher the risk. The math is far more subtle and complicated than that, but that's essentially how it works.

In a recent article in Time magazine (featuring none other than our lovely Laura Collins) about the relationship between anorexia and autism (I've blogged about the subject here), Dr. Kaye said these wonderful words:

"[Anorexia is] highly heritable, it runs in families, and it's clear now that it's affected by a cluster of [early life] vulnerabilities like anxiety and perfectionism. If you don't have those vulnerabilities, you are very unlikely to develop anorexia," says Dr. Walter Kaye, director of the eating-disorders program at the University of California, San Diego..."I think that anorexia is as biological as autism. It's just 20 years behind in terms of research."

A 2005 article titled Anorexia could be caused by brain dysfunction quoted Bryan Lask who explained the biological predisposition as follows:

"The biological cause has been under-emphasised and the socio-cultural pressures have been over-emphasised. There has to be a biological contribution otherwise everyone would be anorexic given the socio-cultural pressures in our society," he said. "I am not saying people are born anorexic any more than they are born asthmatic or diabetic. But I am saying some people are born with a genetic pre-disposition to anorexia which makes it more likely to develop. If you live in a society which promotes thinness as the ideal then you are more likely to develop anorexia if you have the biological predisposition."

Biology isn't simple, though, and no disease--no characteristic, no phenotype--is entirely biological. Environment always plays a role, like Lask said. I have a longer post on this tomorrow that will be full of geeky goodness.

*I got to tell him that I called him my "homeboy" at last year's NEDA conference, which was a combination of funny and embarrassing- for both of us!

Thoughts from the couch

2009-06-18T12:17:00.002-05:00

My therapist gave me a small card last week week, that contained this small magnet and a little message:

1. This too shall pass.

2. Things will get better.

3. The only way out is through.

4. You'll know you're working hard when you feel it.

These are my new favorite mantras, though I personally like my psychiatrist's version of the first one: "This too shall pass, but now would be nice."

Wisdom from Down Under

2009-06-17T15:32:00.004-05:00

Today, I had the great fortune of reading two great pieces from Australia on eating disorders.

The first is an article titled Anorexia's Lifelong Legacy from the Sydney Morning-Herald, about how eating disorder diagnoses are missed in many boys, simply because pediatricians aren't looking for them, and don't think that males get eating disorders. Because proper, quick diagnosis has a large impact on disease outcome, these kinds of stories are very important. Besides covering this timely and important topic, the article did so in a scientifically accurate way. Some of my favorite quotes:

"When kids are starved, their brains shrink, they're more likely to get depressed and anxious, their thinking slows down and memory falters," Madden says. "This affects their relationships with their friends. The effects can be reversed with re-feeding, but not always."

These serious complications can be prevented if children at risk are picked up early. "If children get the right treatment early, 70 to 80 per cent get well in 12 months and 90 per cent are better in five years. This is much better than in adults where the recovery rate at five years is less than 50 per cent," Madden says.

And

Whether an eating disorder can take hold and thrive seems to rest in the balance of risk and protective factors that a person experiences. In the last few decades, the increasing number of risk factors experienced by children - such as stress, anxiety, dieting, body image worries, and exposure to media images and messages that equate fat loss with happiness - may be creating an unhealthy tipping point.

And

The media comes under fire, not as the cause of eating disorders, but as a potent "enabler" of fat phobia, body discontent and restrictive eating in young people...Kohn agrees that children are being influenced by anti-obesity messages. "Vulnerable children hear them in the wrong way and take them to the extreme. Then a physiological mechanism kicks in, reinforcing the behaviour. Eating less and losing weight dampens down the serotonergic mechanism in our brain that processes emotional responses. This makes the children feel better, calmer, less reactive. Their behaviour improves and they get positive feedback, locking in the dieting behaviour."

I wish more articles on anorexia were like this, chock-full of the latest research and entirely lacking in sensationalism and parent- and sufferer-blaming.

The other good read from Down Under is the book "My Kid is Back: Empowering Parents to Beat Anorexia Nervosa" by June Alexander. The book arrived in the mail on Monday, and I've been steadily chipping away at it ever since. As the title suggests, it is more intended for parents than sufferers, and contains the stories of several families who have helped their children conquer their eating disorder. Filled with wisdom and hope, it will be a great read for people needing encouragement along this long journey of recovery. It officially arrives for sale in the US in September, and you can pre-order your copy from Amazon.

Enjoy your Down Under reads- I know I am! Now, about that duck-billed platypus...

The Anorexic's Alphabet

2009-06-15T22:26:00.002-05:00

A is for aspartame, the only sweet allowed.
B is for broccoli, the ultimate safe food.
C is for calorie, which you always count.
D is for diet, that you're always on.
E is for elliptical machine, your BFF.
F is for fat, something you always feel.
G is for garbage, where your food usually ends up.
H is for happy, a feeling you can't remember.
I is for identity, what the eating disorder is.
J is for jealousy, that other women seem to feel.
K is for potassium, always low.
L is for losing weight, your favorite activity.
M is for mother, the cause of anorexia.
N is for nobody, who can penetrate your mindset.
O is for obsession, consuming your every second.
P is for perfection, as you accept nothing less.
Q is for quarter-pound, either too much or too little.
R is for recovery, that seems so far off.
S is for sleep, which perpetually eludes you.
T is for therapy, where your money goes.
U is for U-turn, that everyone hope's you'll make.
V is for vigilance, exercise this or you'll get fat.
W is for weight, of which you can never lose enough.
X is for X chromosome, and it is assumed you have two.
Y is for yourself, someone you no longer know.
Z is for zero, the size you strive to be.

(Sorry for the bit of a downer, but it fits my mood right now. I'm not sure how tongue-in-cheek it's meant to be.)