Study findings:

• Pregnancy rates after 6 months of trying to get pregnancy were lower in women with anoreixa or bulimia
• Women with EDs were more likely to need fertility treatment
• The rate of unplanned pregnancies was HIGHER in those with a history of anorexia

While it took me a few minutes to rationalize how unplanned pregnancies could be MORE common in those with an ED history, I did eventually come up with a few theories:

1. Amenorrhea is deceptive – while lots of people think that you CAN’T get pregnant if you’re not getting your period, it’s just not true.  It happens.  I’d guess this is the largest contributing factor to the higher rate (the article says “underestimating their chances of conceiving,” but they’re probably one in the same).
2. Periods are undesirable — meaning, when you don’t have a period, opting to go on birth control and get one seems… ludicrous?  I know people feel very differently on this subject, but I’m just saying, amenorrhea can be kind of convenient.
3. Sexual abuse history — many women with EDs have some kind of trauma history, and there is a lot of research out there suggesting that women who suffered sexual abuse have an increased risk of early and/or unplanned pregnancy.
4. Invincibility — you know how you’re told all those risks of having an ED, like heart attack, osteoporosis, esophageal tear (not to mention DEATH), and you think “yeah, whatever?”  I think that could definitely apply to the “it’s not going to happen to me” mentality of unplanned pregnancy.
5. Self-care deficit – maybe it’s not “it won’t happen to me,” so much as “I don’t care.”  When you don’t have a lot of respect for your body (or, you WANT to hurt yourself), there isn’t a lot of motivation TO use protection.
6. Birth control effectiveness — some antidepressants reduce the effectiveness of birth control, and I’d venture to say that more than half of people with EDs are on some kind of medication for a mood disorder.  Also… while I’m probably grasping at straws here, I’d also bet that purging is not great for effectiveness when on the pill, either.

If there’s one thing that you take away from this post, I hope it’s this: You can get pregnant even if you don’t get your period.  Really. 

There was a post on Lifehack the other day called, “3 Reasons Why Shame is Your Friend.”  I saw that headline and of course HAD to read it. It turns out it’s the third in a series, after “Why Fear is Your Friend”  and “Why Sadness is Your Friend.” How many times have we talked about these things in therapy… as negative influences?

Personally, they’re all pretty interconnected for me. I’m all about avoiding everything (seriously), and a lot of that is probably fear-based. I’m afraid of screwing up, I’m afraid of being attention-seeking, I’m afraid of being too needy, etc. And, a lot of those fears probably stem from shame. I’m ashamed that I’m not good enough, I’m ashamed that I want attention, and I’m ashamed that I ask for too much.

Now, throw in sadness, and you have a whole cycle. Shame –> Fear –> Sadness –> Fear –> Shame. Avoiding everything does not lead to happiness, that’s for sure. When you act on all those fears (meaning: don’t try things new things you could screw up, don’t develop relationships where you might need something, don’t allow others to care for you because you don’t want to demand “too much” attention), you feel depressed! I end up lonely, bored, and pretty hopeless.

So, how does Lifehack argue that all of these negative emotions are “Your Friend” ?

• Fear
  • Guides you towards what’s important for you
  • Motivates you to take action
  • Gives you a rush
• Sadness
  • Shows you what you care about
  • Helps you to appreciate what you have
  • Requires you to be authentic
• Shame
  • Shows you what you believe about yourself and what your vulnerabilities are
  • Deflates your ego
  • is actually a back-handed compliment

Read: they’re all red flags. I guess you could make that argument for every feeling, and that’s why you’re not supposed to label them as “good” or “bad.” Take the point about shame indicating your vulnerabilities, for example:

Now, when someone calls me ugly, I feel a flush of shame, because when I was a kid, I felt ugly, and part of me still feels that way sometimes, so that indicates that I am still carrying around that belief about myself, buried in my subconscious. When someone insults you and you get upset, part of you believes the insult might be true, that’s insight into what you believe about yourself, and it indicates what you might want to work on as personal growth.

Maybe if I just thought “hey, that triggered some negative belief about myself that I’m still carrying around from my childhood” whenever I screwed something up, shame wouldn’t feel so awful. But, that seems to require a lot of faith that whatever negative belief isn’t actually true.

Earlier, I said that “avoiding everything does not lead to happiness.” For me, I don’t think that happiness is even my goal in avoiding unknowns. It’s the belief that taking the risk isn’t worth it. That maybe the hurt of rejection, abandonment, and disappointment is too much to handle.

Clearly my thoughts are all over the place, but my point is really that while fear, shame, and sadness all tell/show you things, it’s what you do with that information that matters. I’m very capable of connecting: relying on other people > being vulnerable > shame that I can’t do it on my own > probably some maladaptive core belief that I’m not enough or that needing help isn’t okay. That’s exactly why I avoid it! Again, this leaves me at the great chasm between knowing and doing.

Common reasons that patients quit treatment (patient perspective):

1. consider “treatment to be inappropriate”
2. sufficient progress
3. not enough freedom
4. group therapy is too difficult
5. worried about work / school consequences

I can’t help but think that some of these tidy explanation are really code for a different (possibly disordered) thought. Here’s my take on what each of these mean:

Consider “treatment to be inappropriate”
Read: “I’m not sick enough”
I wonder if this is completely different from the “I’m not sick enough” idea. It makes sense — during the course of treatment, not only are you (likely) gaining weight, decreasing behaviors, and getting better overall, but you’re also experiencing the admission of new and sicker patients. At some point you start to feel like you don’t belong there.

Sufficient progress
Read: “I’m bored”
Treatment gets boring after awhile, and I think that “I’m ready to discharge” often gets confused with “this is getting old and I want to discharge.” Plus, at some point the initial challenges aren’t challenging anymore. That IS the goal, right? Anyway, when you get tired of treatment, you start thinking “I’m doing well enough to discharge….”

Lack of freedom
Read: “I’m tired of being treated like I’m five.”
It’s crazy how one day you are in the real world and can do whatever you want, and the next day you can be in treatment and have to ask permission to go to the bathroom. Not only can you go stir-crazy from not being able to leave the treatment facility, but it can be frustrating to feel like you always have a babysitter.

Group therapy is too difficult
Read: “I don’t want to talk about this in group.”
Unless it’s some triggering trauma group, I think the most difficult part of group is the fact that it’s a GROUP — not an individual session. There are things that are too hard to talk about outside of your therapist’s office. Having to try and discuss tough things in a group setting and be okay with that is really hard.

Work / school consequences
Read: “I’m screwing up my real life.”
It’s not easy to leave school or work and put your life on hold to go into treatment — however necessary it may be. And, unfortunately, it doesn’t always work out so well either. Often people do lose their job (I know legally they can’t fire you on medical leave, but you’d be amazed how many ways around this stipulation there are!) or have to withdraw from the semester. You need a life to go back to when you do discharge.

Maybe I’m just less honest than all the patients in the study, but I feel like I’ve used every excuse in the book before, and usually they are not as straight-forward as they seem.

Before proceeding, I should probably define medialization, per Simone Rodder’s article, “Reassessing the concept of a medialization of science: a story from the ‘book of life’“:

“The concept of medialization is used to describe the centrality of the media for the communication in society and processes of an orientation of social systems toward the media.”

She then breaks down the concept of medialization into two aspects:

1. increasing media attention for scientific issues
2. increasing orientation of science towards media

This was interesting to me, since you hear a lot about journalists sensationalizing science to produce an interesting story, but not so much about the scientific community distorting their findings to gain more press. There’s another great article — “The media’s and health scientists’ perceptions of strategies and priorities for nurturing positive scientist-media interaction for communicating health research in Uganda” (link to full pdf) — that further explores this scientist-media-society interaction:

“The most common errors in science journalism include omission of critical information and context, misquoting, simplification or sensationalization of headlines.”

“The mass media (radio, television or newspapers) plays a central role in provision of timely and reliable information to the public, fellow scientists and policy makers. The mass media is ofted cited as a primary source of health information.”

Anyway, given all of this information, my next thought is: so what about the influence of social media? Blogs, facebook, twitter, etc.

I think that social media is creating a new kind of medialization — one where you don’t have that intermediary between researchers and the public. Sure, I retweet news articles all the time, but I can also talk to psychologists, doctors, and researchers directly. Now, I wouldn’t consider twitter “a primary source of health information,” but it is a growing medium for all kinds of information… and I do think it’s going to influence this dance between science, media, and society.

How social media affects medialization:

1. Increased specificity of information — either you search for someone well-versed in exactly what you’re curious about or you ask a specific Dear Abby-ish question. The info can be so highly-personalized.
2. Decreased scientificness (I know that’s not a word) of information – aka: more “professional opinions” — Even if the info is way more relevant and interesting than a journal article, it’s not necessarily scientific.
3. Increased availability and variety of information – with the ability to connect to people directly, you have an unlimited number of sources from which to get information. You’re not relying on CNN to interview Dr. Sanja Gupta… you can ask whoever you want. And hey, maybe it’s a doctor… or maybe it’s a yoga instructor.
4. Information is dynamic and interactive – social media conversations are much more interactive than static news articles. In some instances, you’re mixing a few professional opinions with many non-professional opinions.
5. Scalability and/or reach — when you have a large article in the Times, that particular story is popular because a million people are reading it. However, when you have a trending topic on Twitter, a million people may be tweeting about it but only a dozen are seeing each tweet.

The influence of new social media does eliminate many of the barriers to communication that were outlined in the perceptions of strategies article, such as “lack of knowledge by scientists about how to disseminate research” and “poor working relationship between the health scientists and the media.” However, social media has at least as many problems as traditional media. I’m sure that you can take any of the factors that I’ve listed and identify how they are detrimental. Maybe… the evolution of medialization is just different; not necessarily better or worse.

“By regarding a phenomenon as a psychiatric diagnosis–treating it, reifying it in psychiatric diagnostic manuals, developing instruments to measure it, inventing scales to rate its severity, establishing ways to reimburse the costs of its treatment, encouraging pharmaceutical companies to search for effective drugs, directing patients to support groups, writing about possible causes in journals–psychiatrists may be unwittingly colluding with broader cultural forces to contribute to the spread of a mental disorder.”

“These reflections force us to think about the question whether, by publishing this study, we are part of the social construction of “new” disorders? Perhaps that is unavoidable. With this study we are exploring the borderlands and cross-overs between scientific and popular discourses about health and illness. We are facing an increasing media attention for scientific issues on the one hand and an increasing orientation of science towards the mass media on the other hand. The medialization of science, when applied to medicine, can get intertwined with another powerful process of a two-way relationship between medicine and mass media: the medicalization of our society, of which the dissemination of diagnostic labels is a classic symptoms. The two sociocultural processes, medialization and medicalization, actually culminate in cyberspace. With this study we are, so to speak, participant observers at the crossroad of these processes. By publishing about it in a scientific journal we not only are becoming part of this medi(c)alization but also, unwittingly, we may shape and fuel it!”

I think about that last statement all the time whenever I see media attention on eating disorders. While I don’t really want to promote ignorance, sometimes I think that any attention is negative attention — this blog included! It’s a kind of catch-22: the public needs more information to decrease the stigma of mental illness, but at the same time you are “unwittingly colluding with broader cultural forces to contribute to the spread of a mental disorder.”

How many times have you heard about the influence of culture in the development of eating disorders? Fashion, society’s obsession with thinness, celebrity-whatever, etc. You hear about it all the time. Heck, you have groups about it in treatment! However, given this idea that just “regarding a phenomenon as a psychiatric diagnosis” is enough to influence society in an unhealthy way, then essentially even treatment could be viewed as a perpetuating factor of mental illness. Maybe that seems a little extreme, but it’s something to think about.

In a conversation with my friend Emily, she countered by explaining the following:

“While mental illnesses are to some extent social constructions, the thing about research is that you are creating new knowledge by observing and writing about it. While new diagnoses may be fads, they also are probably worthy of additional study and analysis. It’s only through additional study that scientists can determine if they are worthy of being called an official diagnosable disorder. Since psychology is a social science there is far more grey and societal norms influence what is deemed as being pathological…. and since social media is a growing part of our society, it seems understandable that it would have an influence on pathology and symptomology. It also begs the question as to whether or not the DSM is only reliable as a diagnostic resource in western countries.”

Wow, lots of good points and things to toss around. The social media factor is something that I’m going to blog about tomorrow, so stay tuned….

A recent article was published on “Psychological inflexibility and symptom expression in anorexia nervosa.”  It makes a lot of interesting points on controlling the bodily experience, using verbal rules to deal with fears, maladaptive social scripts, etc, but what really interested me was the distinction between psychological inflexibility and perfectionism.

Definition of pyschological inflexibility (according to the journal article):
The inability to behave flexibly in the presence of difficult thoughts, feelings, and bodily sensations.

Definition of perfectionism (acording to wikipedia):
The unitary combination of a desire to be perfect, a fear of imperfection, and an emotional conviction that perfection (not “near-perfection”) is the only route to personal acceptance by others.  The difference [between perfectionism and striving for excellence] is in the meaning given to mistakes. Those who strive, however intently, for excellence can simply take mistakes (imperfections) as inducements to further learning and work. Perfectionists take mistakes as signs of personal defects that make them less acceptable. Anxiety over potential failure is the reason perfectionism is felt as a burden.

I think this is a great distinction for several reasons:

1. “psychological inflexibility” encompasses more than just perfectionistic tendencies
2. the word “inflexibility” suggests something problematic
3. perfectionism is not necessarily a bad thing
4. perfectionism is a personality trait, which may not change even if someone does completely recover from their eating disorder

By examining psychological inflexibility rather than perfectionism, the study was able to separate perfectionistic thoughts from actions/consequences.  Meaning, you can still have perfectionistic thoughts without reacting to them negatively.  This lead to several great findings:

“Although the frequency of perfectionistic cognitions did not change, adolescents’ reported decreased distress in response to those thoughts.  Importantly, decreased distress was associated with reductions in dietary restraint and lower global scores on a structured interview of eating disorder symptoms when baseline levels of symptoms were controlled.  This is consistent with studies of adults with AN that have reported greated acceptance of negative thoughts and feelings about weight and shape corresponded with ED symptom improvement in the absence of any significant change in the content or frequency of the thoughts and feelings themselves.”

and then

“Lower levels of psychological flexibility distinguish individuals with full syndrome AN from those who are weight restored and health controls, while the ability to engage flexibly with distressing throughts and feelings is associated with AN symptom remission across treatment.  Perfectionism and related cognitions which have long been desribed as part of the phenomenology of AN, do not change in frequency but in impact as a result of successful intervention, suggesting how individuals with AN relate to these thoughts may be of prime importance.”

Maybe one of the goals of treatment, then, is not to eliminate perfectionistic tendencies, but to change your reactions to them.  Distress tolerance.  “It’s not perfect, but I can deal with that.”  I don’t think it’s really the perfectionism that’s the problem, so much as the interpretation/internalization of what a mistake (or being out of control, or uncomfortable emotions, etc.) means.

People have this inclination to do more, even if what they do is trivial.

Experiments have shown that the desire for activity is quite strong; people will go to a lot of trouble to maintain their desired level of activity, which can include unhealthy behaviors. Many psychologists have “the idea that people have these highly specific goals,” Albarracin says. “But quite often some significant proportion of our time is engaged in this global level-we want to do something, but what we do ends up not mattering much. You could end up with productive behavior, like work, or impulsive behavior, like drug use.”

The eating disorder takes so much time and mental energy. You’re thinking about your weight, body image, how whatever you’re wearing makes you look fat, what you ate today, what you ate yesterday, what you’re going to eat tomorrow, when you’re going to exercise, how you are going to binge/purge, etc etc etc.

It’s exhausting… but it also keeps you pretty occupied. You feel like you’re doing something, and it even feels productive — like you are changing or working toward some greater goal.

I think there are lots of reasons why I choose to obsess over ED stuff rather than something healthier. It’s easier, more in my control, fixable, and totally conflict avoidant — just to name a few. For that reason, I know that boredom, lots of unstructured free time, and feeling unsatisfied (especially with work, but with anything in life, really… I’m very equal-opportunity when it comes to identifying flaws) are big triggers for me. I want to fill that time or hole with counting calories, obsessing over weight, exercising… you know.

I have a friend who’s therapist told her that she would know French right now if all the space in her brain that she was using for nutrition facts was filled with a foreign language. Sometimes I think about that – who knows what I could have learned or accomplished had I spent those thousands of days doing something a little more significant…

The “Is this going to work for me?  Which of the hundred side effects am I going to experience?” mystery reminds me of this food seasoning that my uncle has, called “magic dust.”  The “magic” is that it tastes completely different depending on what you use it on (chicken, fish, etc).  It’s become the family joke that we use magic dust on everything.  My mom could bake cookies and we’ll ask if she used magic dust in them.

Lately I’ve felt like psych meds are like magic dust — the are used for everything and work differently for everyone.  Sprinkle a psychotropic on individuals with different diagnoses and you get different results.

Let’s take Lamictal, for example:
Seizures — I’m on this med for seizures.  It does NOT help my headaches (in fact, I think it makes them worse) and it makes me tired.  It also does nothing for my depression… in fact, I think it makes that worse, too.  It’s feeling very un-magic to me right now.
Bipolar —  Friend #1 was on Lamictal for bipolar disorder.  She did think it helped with mood stabilization, but she couldn’t sleep while she was on it and had blurred vision.  I wish I could exchange my fatigue for her insomnia right about now.
Depression — Friend #2 was on Lamictal for depression.  She experienced a hundred side effects (including the notorious rash) and loathes the drug.
Migraines — Another off-label use for Lamictal is migraine prophylaxis.  How unfair is that?  I guess that magic is lost on me, too.

And, don’t even get me started on Wellbutrin.  Depression?  Smoking?  Weight loss?  ADHD?  Is there anything (okay, besides seizures) that for which psychiatrists can’t use Wellbutrin?

While real magic dust makes everything taste good, this psych dust often just gives everyone different side effects. The promise of pharmacogenomics is actually the opposite of magic dust.  It’s personalized dust.  I know, I’m overusing the dust analogy… but that’s what I want: personalized dust.

Now, when it comes to cooking… well, that’s a different story.  I kind of wish you could even put it in cookies.

Any kind of media or literature has to tread that thin line of being honest and informative without being triggering — and really, I don’t know if there’s actually even a line. What’s helpful for one person is triggering for another. Take Marya’s “Wasted” for example. When I first read that book i wanted to highlight 50% of it. It felt like she had put my jumbled thoughts into cohesive sentences that I could completely identify with. With that said, I definitely tried eating carrots with mustard at one point. Yuck. (if you haven’t read the book, just ignore that reference.)

In my own treatment experience, professionals have been all over the spectrum when it came down to whether or not reading ED books were disordered. One therapist thought reading them was a kind of glorification of the disorder itself. Another felt they are just another manifestation of the food/weight obsession. Another therapist gave me a list of ED books to read. A nurse practitioner once gave me a copy of the Eating Disorder Sourcebook. I’ll save you the trouble of reading it — unless you’re looking for a long extension of the DSM criteria, you can skip it. I can think of several non-disordered reasons to read ED novels:

1. It’s validating to hear your concerns / issues articulated by someone else.
2. Seeing how others overcame their struggles can offer hope.
3. Some stories are depressing enough to make you think “wow, I so don’t want to do that.”
4. For information (not all info fuels your ED).
5. You’re in High School and Wasted is on your summer reading list (I noticed that on a required reading list for a nearby school last summer).

So, disordered or not? I guess it depends on where you are in your disorder and recovery. Generally my philosophy is if you want to read an ED book, go for it. Read a dozen. You probably won’t want to read many more than that, because they get boring — Well, unless you branch out into books on psychotherapy or CBT or PTSD or whatnot. With many ED biographical / autobiographical novels, you’re going to see the same pattern: person develops ED, person receives treatment for ED, person continues relapse/recovery cycle, and person may/may not recover. However, I do 100% support reading psych journal articles (totally different!)… but I’ll save that post for another day.

Therese refers to the tips/tricks she picked up in therapy as “emotional CliffsNotes.” Ever since reading the book, I’ve thought about what I would put in my own emotional CliffsNotes. I have a friend who would probably say I’m just looking for an excuse to make yet another list — which may be partially true — but hey, if I can make a blog post out of it too….

Anyway, a couple of months ago I ran across an awesome article over at Stepcase Lifehack, called “Can You Transform Without Getting Uncomfortable?” Craig’s main point was this:

Hypothesis: There is a positive correlation between how uncomfortable an individual is prepared to get and their likelihood of success – irrespective of the field of endeavor.

This idea reminds me of something my therapist told me once: that anxiety is a good thing. I thought she was nuts (or just wrong) at the time, since I was devoting so much time to controlling/minimizing anxiety. She explained though, that when you’re feeling anxiety, that’s when you’re making progress. The mental anguish that comes with facing uncomfortable things (like eating more, weight gain, handling conflict, being assertive, etc) is a good thing.  It means you’re making change… and that’s what you have to work through.

It was really weird for me to look at anxiety as some positive indicator of change rather than some big red “stop! uncomfortableness ahead!” sign. What I got out of the conversation at the time was that if I were waiting for recovery to be comfortable, it was never going to happen. Challenging the eating disorder was never going to feel good (at least not while still in the thick of it).

Reading Craig’s article put a different spin on it for me, though. I was still looking at anxiety as something inevitable that I had to push through to get to the other side. The blog post opened me up to the idea that uncomfortable does not equal bad. It’s just uncomfortable.

By the way, I’ve been meaning to write this post for a month (at least), but was re-inspired by something that I read on Carrie Arnold’s blog today:

The main factor for me was anxiety and fear about changing my behaviors. I was often tired of the eating disorder but unable to push through the anxiety that was keeping my ritualistic behaviors in place. Thus the status quo remained in place. My other issue was that this fear was coupled by my minimizing the issues that my AN behaviors created. They weren’t that bad, I could handle it, most people were on a diet- how was my life different? So how could I be motivated to work on a problem that I often wasn’t even sure I had?

I know that anxiety! It keeps me stuck, especially when it comes to the eating disorder.