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. 

Intelligent behavior requires strategic processing of numbers and abstract quantity information in accordance with internally maintained goals. For instance, we typically adopt a “less than” strategy when shopping for a product to pay the smallest amount of money. When searching for a job, on the other hand, our plan of action is “greater than”, and we strive to earn the largest sum of money. In such pragmatic situations, our decisions on quantities are guided by mathematical rules applied to them.

The monkeys learned the quantitative “greater than/less than”-rule and were able to choose the smaller or greater set size relative to the sample numerosity, independently of the absolute numerosity of the displays. While the animals were performing this task, neurons recorded in the prefrontal cortex of the frontal lobe exhibited interesting activity. Irrespective of the absolute magnitude of the dot sets, the brain cells exclusively represented the mathematical rule at hand. Approximately one half of these neurons were only active whenever the animal followed the “greater than”-rule, whereas the other half preferred the “less than”-rule.

“This new study provides valuable insight into the neurobiological foundations of highly abstract thinking that is necessary for mathematical operations. “First of all we want to understand how neurons process mathematical operations” Andreas Nieder explains. “At the same time, our investigations of the number sense are meaningful for assessing the very complex thinking processes that are necessary, for instance, when dealing with numbers.” It is the cerebral cortex at the frontal pole of the brain that constitutes the brain’s highest cognitive control center. This region of the brain also gives rise to mental activities that build personality.”

I think that the “greater than/less than”-rule could definitely apply to eating disorders.  You’re looking for the fewest calories when grocery shopping or at the gym calculating which exercise burns the most calories (these are pretty stereotypical examples, but stay with me).  In many ways, common eating disorder rules do involve a kind of math.

I’m stepping out of my realm of knowledge now… but I wonder if these rules could be applied to anxiety.  What about choosing the activity or food that causes the least amount of anxiety?  That’s math-like… I’m assessing the situation and choosing the smaller action relative to possible anxiety.  Am I stretching this?

Also, I think it’s an interesting connection that the cerebral cortex impacts mathematical processing AND personality.  There is definitely a relationship between how immersed one is in his/her disorder (which could mean more rigid adherence to self-imposed ED rules) and presence (or absence) of his/her personality.  I know there are lots of other biological explanations for this (I think every eating disorder blog is required to mention the Minnesota Starvation Experiment in at least one post)… but I think the possible connection is fascinating.

“Currently, we are concerned about young people using the Internet, eating too much, spending irresponsibly, and being promiscuous, and these worries are being expressed in the language of addiction. The medical terminology helps us to believe we’re avoiding moralization or blame, and popular science has given us a sound bite of pseudo-neurology to support our prejudices. For these problems, addiction is little more than a fig leaf for a realistic understanding that would address why people return to unhelpful ways of coping with isolation, stress, and depression. Instead, we prefer to rely on a trite and unhelpful catch-all label that prevents people from getting appropriate help for their difficulties. We need to break the addiction habit, before it breaks us.”

–Slate, The Addiction Habit

My first thought when reading this article was “ouch.” I’m not an addict, but still, that’s a pretty strong statement. Addiction as a fig leaf. Hmm…

I’ve written a post on this before (A diagnosis for everyone), which would largely agree with the author of the mentioned quote. I do think that the addition label is used too literally.

However… after having watched Sex Rehab, I have a slightly different view on the subject. In terms of true addiction, I’ve always really only considered drugs and alcohol as qualifiers. I wouldn’t even say an eating disorder is an addiction (although many would argue with me), just because there isn’t one identifiable thing that you are addicted to. There are a lot of similarities between the two, though. Anyway, that’s a debate for another day.

Regardless of whether sex addiction is a “real” addiction, these people came and got help. There was much more that they needed to deal with than just the sex – most of them had either some kind of abuse history, unresolved issues that were affecting their daily lives, or an underlying drug/alcohol issue. Whether or not sex addiction “counts,” these people were really struggling with a lot of stuff in life. They definitely left in a better place than they started, and I’m sure that the ongoing treatment can help them be healthier, happier people with satisfying relationships (hopefully).

They wouldn’t have made these changes unless they were removed from their everyday lives. They needed a rehab. They wouldn’t have gone to rehab unless they had a real problem, though. If sex addiction didn’t “count” as real, who knows if they would have ever gotten help.

So I guess my point is… yeah, the word addiction is definition used too liberally. Internet addiciton and sex addiction are most likely in a different category from substance addiction. However, I disagree with this part of the quote:

“…we prefer to rely on a trite and unhelpful catch-all label that prevents people from getting appropriate help for their difficulties.”

I think that MORE people get help when their struggles are verified as real problems. If you spent your entire adult life playing online role-playing games, to the detriment of your career and relationships, then yeah, I’d say that’s a problem? An addiction? ehhh… I don’t know. But if labeling it as such would give someone the permission to get help for something they can’t get over on their own (isn’t that largely what it comes down to? getting help for a problem that you can’t handle by yourself? that’s hurting you, your loved ones, and your life?”), then sure, call it that.

Maybe we shouldn’t call these behavioral obsessions “addictions” – but we should come up for something that validates them. The article makes a relevant point:

“Recent work by psychologist Meredith Young and colleagues at McMaster University in Canada has shown that if we replace a common name for an illness with a medical term—pharyngitis for sore throat, e.g.—people tend to perceive the illness as being more serious.”

Okay, so come up with some scientificish name! Someone must know what “behavioral obsession” is in Latin. Just give it a real name so people can recognize it as a real problem.

“…individuals with low self-esteem actually felt worse about themselves after repeating positive self-statements.”

“…paradoxically, low self-esteem participants’ moods fared better when they were allowed to have negative thoughts than when they were asked to focus exclusively on affirmative thoughts.”

Now, I don’t think I’ve ever claimed positive self-talk caused anyone to feel worse… but personally, I’ve never found it helpful as a coping mechanism. The results of the study do make some sense to me, though. Saying completely untrue statements like “I accept myself completely” make me feel further from that as a goal. I start to think, “Will I ever really accept myself completely? What’s wrong with me that I can’t right now? Does it matter if I do? Will I really feel better if I do?”

Also, the article makes a good point with being “allowed to have negative thoughts.” I think that often only positive affirmations are used in treatment in recovery. Things like “Everyone can get better,” “I know that you will beat this, you are such a strong person,” “You have too much potential to struggle with this forever,” “You’re making amazing progress,” etc. are all meant as motivational compliments. Maybe for some people they are… but again, I am backwards and actually feel a little invalidated when I hear how awesome I am doing in recovery. I don’t mind my therapist telling me I’ve made a lot of progress, but I do mind being told that I am doing great when I am feeling crappy. Additionally, sometimes I do worry that I will never get over this or that I will be considered “recovered” once I am 100% ideal body weight, regardless of whether or not I feel mentally/emotionally okay. I’d rather be told that she (therapist) knows that I am struggling and that she is there to support me, and that those fears are understandable becuase people do die from this illness or suffer from it their entire lives, but that I’m in treatment and working for something better than that.

I would love to see if there is a difference between others giving you affirmations vs. you creating them yourselves. I have a letter from an old therapist that says “you are more than enough” as well as a card from a different professional that says, “there are people who care deeply about you.” Both of these are comments that I could tell myself (I am lovable, my family and friends love me, etc.) but they are only significant because I care about and really look up to the people who gave them to me. I guess that’s what makes it so different from positive SELF-talk.

To summarize:

Because her health is directly related to her weight.  Measured by scales.
Her recovery is directly related to her weight.  Measured by scales.
Her life is directly related to her weight.  Measured by scales.
Weight matters.
And scales matter because they measure weight.

I posted a comment on this post, which hasn’t been approved yet, but I decided that I wanted to discuss the issue on Grey Thinking anyway.

Yes, weight is inexorably tied to health and to recovery.  Weight restoration is vitally important to recovery.  You can’t be recovered and still be below the healthy weight range.  Professionals need to monitor weight.  Some treatment decisions need to be made based on weight.  In short, I am not at all arguing that weight is unimpotant for recovery.

With all of that said… I find a lot of diagnostic criteria and treatment approaches to be contradicting and frustrating.  In therapy, you’re told that you are not a number.  That you are lovable regardless of what the number on the scale says.  That coping with food / weight is not okay.  That eating should be mindful and emotional eating is unhealthy.  You don’t have to be sick to deserve care.

But think — how is your health measured?

• weight, BMI, % of IBW
• calories, exchanges, % of meal plan completed
• heart rate, blood pressure, potassium, electrolytes
• # of binges / purges, # of laxatives, # of diet pills
• hours exercised

… see my point?  Everything is measured in numbers.

I have an issue with your mental health being measured in numbers.  From this point of view, gaining weight = a good week and losing weight = a bad week.  That has just never been a linear relationship for me.  I have bad weeks and gain weight, and vice versa.  Sometimes I follow my meal plan and lose weight, and other times I restrict and gain weight.  The system reinforces the necessity of communicating through your eating disorder.  If you’re feeling crappy but follow your meal plan, then obviously you weren’t really feeling bad — if you were, you would have restricted.  Plus, when you are at a healthy weight — ta da, end of treatment!  You’re all better!  Even if you feel as crappy as ever, you’re not sick anymore, so…..

Thankfully not all professionals practice this way, but measuring your progress in recovery by numbers is not unusual.  I feel strongly that weight is just a piece of the puzzle… and while weight and eating are core components to eating disorders, by basing treatment on just these factors you are really limiting treatment.  There are people who will stay sick because the system inforces that they need to be to get help.  And that’s unfair…

“You get to define which experiences are traumatic for you, whether or not it would impact others in the same manner.  It’s not the objective facts that determine whether an event is traumatic,  but your own emotional experience of the event.”

– Dr. Kathleen Young

This is just a quick post, but I read this on a trauma blog tonight and thought it was so well-put.  This is something that i struggle with a lot — whether or not something “counts” as significant.  Maybe I am making it up.  Maybe it was no big deal and I should have been fine.  Maybe I am fine and am just crying wolf.

I’m not even limiting this to trauma — of course I can extend it to eating disorders, too (because I have to somehow relate everything to eating disorders, or so it seems).  There’s always that fear that maybe I’m not sick enough to actually need help.  It’s not that I want to be sicker; I’m just afraid of asking for help that isn’t justified.  What if someone else in my position wouldn’t need help?  What if I’m actually okay-enough?

It is such a good reminder for me that my “own emotional experience” is my reality — and in the end, that’s what is important.  Regardless of whether or not it should “count” as significant, it affects me, my sense of self, my relationships, and my future.

1. Bulimia Nervosa (BN) is an addiction rather than an eating disorder
2. Black females are 50% more likely to be bulimic than white females
3. “Bulimic behavior” is less likely among wealthier, better-educated families.

You should definitely read the article, but I have a couple of things to add to these points:

1. BN is an addiction
I always compare eating disorders and addictions — but I still wouldn’t put BN and alcoholism in the same category.  There are several key differences:

1. Lack of an addictive substance: Addictions require you to be, well, addicted to something — alcohol, opiates, cocaine, etc.  With bulimia, there’s no addictive substance.  I don’t think you can even argue “food” as the addictive substance.
2. No healthy use for symptoms: Occasional purging is not okay or normal.  I’d argue that anyone who purges has an eating disorder (at least on some level).  However, there are appropriate uses for alcohol, opiates, and even cocaine.
3. Goals of treatment: With addictions, the goal is to abstain from the addictive substance.  However, you can’t abstain from food (maybe from purging, but again, that’s only half of it).
4. Psychopathology: “Addict thinking” is not really the same as “eating disorder thinking.”  Similar — but not the same.

2. BN more common in black females
I don’t have much to say about this one, except that I’m skeptical.  I don’t think EDs are limited to certain races, but I think that if you looked at the cultural make-up of treatment centers, you’d find this claim to be false.  Yes, this is measuring those in treatment vs. BN prevalence — and there is likely a difference — but not a 30%+ difference!

3. Bulimia less common in upper-class families
Similarly, I don’t think that BN has socioeconomic limitations…

If for no other reason, the article at least challenges the many ED stereotypes.  It’s curious to me that a) there is no reference to males with eating disorders and b) the study is unique to bulimia.  I’d be interested to see if authors found similar results with anorexia.

That said, I am a little disappointed to read this article on relationships and mental health:

A partner is four times more likely to leave you because of a mental health condition like depression than because of a physical disability.

The survey, which asked people about issues that would make them break off a romantic relationship found that 20 per cent of British women wouldn’t stay with someone if they were diagnosed with schizophrenia, yet only a few of them would break up with someone who became disabled and needed to use a wheelchair.

The article chalks up the entire discrepancy to stigmatization.  Naturally, I think that there are other elements contributing to this problem:

1. Personality changes – I think the biggest issue is that mental illness has a larger impact on your personality, mood, and temperament.  It’s not easy to be around someone who is really depressed.  You want to connect with your partner, spend time with them, and in general just be happy to be around them.  Most mental illnesses cause people to push others away, be irritable, isolate, etc.  These qualities are not very conducive to relationships.  In high school, my eating disorder definitely affected my relationships.  I didn’t want to go out to eat.  I didn’t want to see a late-night movie because I was too tired.  I took everything personally and was really depressed.  I was much more interested in the disorder than in my relationships.  I was not a fun date (to say the least).
2. Expectations of recovery – I think that it’s frustrating to be with someone who you feel should be getting better, but isn’t.  If you are in a wheelchair (to continue with the article’s example), you might never be expected to walk again.  However, if you have an eating disorder, you are expected to get over it.  It’s tiring to spend years and years worrying about someone who is continually in and out of treatment, rarely making significant gains in their recovery.  Your expectations are different.  Realistic or not, it can be exhausting to watch someone chronically struggle and feel like they don’t necessarily even want to get better.
3. You don’t know what you’re getting into. When you start dating a guy in a wheelchair, you know he’s in a wheelchair.  You very well may not know that your date is bipolar, though.  Again, it’s an expectations thing.
4. Baggage. As non-PC as this is, it’s true — mental illness carries a lot more emotional baggage than physical illness.  Someone with a mental illness is more likely to have a familial history of mental illness, childhood abuse, an alcoholic parent, or some other kind of trauma.  Eating disorders don’t develop in a vacuum, right?

Naturally, I wouldn’t discourage anyone from dating someone with a mental illness.  Actually, I don’t even like the “mental illness” label.  If we’re all on a mental health / mental illness continuum, then where do you draw the line, anyway?  (this is a discussion for another time!)  I just think that there’s a lot more at play than just stigmatization.

According to Twin Cities, the patient load at Park Nicollet’s Melrose Institute/St. Louis has increased by 36 percent from one year ago, while the patient load at The Emily Program/St. Paul has increased by 20 percent for the same time period.

For instance, he says, people who suffer from an obsession with their weight, but who exercise to control weight gain rather than starve themselves, may no longer be able to afford their gym memberships. In that case, Jahraus says, they may decide to limit their food intakes, which can lead to eating disorders.

Oh, this article could have been so interesting! It was an interesting thought. The part about not being able to afford your gym membership and therefore developing an eating disorder killed the article (for me), though. Oh well…

Still, I wouldn’t jump to the conclusion that a bad economy spurs eating disorders… but rather that a bad economy motivates more people to get help for their eating disorders. Why is this?

Well, I think that there are several reasons….

1. A big barrier to treatment is work. You have responsibilities… you can’t just disappear for a month or two to go into treatment all day. If you are laid off, though, suddenly you are available in the middle of the day. You don’t have another commitment. You have time to get the treatment that maybe you’ve needed for a couple of years but never felt you had time to get.
2. Feelings of disappointment, shame, and embarrassment. These are tough feelings for anyone, but are especially tough feelings for someone with an eating disorder. It’s not unlikely for someone with an ED to take being laid off personally… as if they somehow failed. They might think it is a reflection of themselves — they’re not good enough. What are they going to tell friends and family? Others will be so disappointed. When you’re feeling this depressed and hopeless, you’re more motivated to go and get help — you don’t want to feel like this.
3. Lack of structure. Many people with eating disorders struggle with endless periods of free time. Work provides a daily structure that’s helpful. When you are missing that, sometimes things fall apart. Maybe getting intense treatment will help you with that transition… to either help you figure out how to cope with the free time or to tide you over until you get a new job.
4. Friends and family have time to notice your issues. If you’re at work all day, your friends and family might not realize how little you’re eating or how much you’re exercising. When you’re suddenly at home all the time, they have a much clearer picture of what your eating/exercising habits are like during the day… and they might be concerned and encourage you to get treatment.

I have never gone to the dentist and wanted anything to be wrong. In fact, I’d pray, “Please please please let everything be okay. PLEASE.” During my worst ED points, I’d avoid the dentist completely. I was sure that purging and restricting and whatever else was not good for my teeth (or gums). I did not want to have to explain anything to my dentist. Having seen a few not-nice dentists in my past, I also did not want to be told “how bad what I was doing was for my teeth.” (No kidding, I know that.)

When it came to teeth, I was embarrassed about the ED. It’s hard to explain why I wasn’t so ashamed when it came to other medical issues… but I think it’s because:

1. Dentists probably aren’t trained to deal with EDs
2. Everyone wants nice teeth
3. I felt totally irresponsible not taking care of my teeth. Cavities and whatnot just did not mesh with my perfectionistic drive.

Finally I decided that maybe if I paid a dentist enough they would have to be nice. Isn’t that how things sometimes work? Maybe if I just found an expensive dentist, then he wouldn’t want to offend me by suggesting I had an eating disorder. In hindsight, I don’t know how much sense this actually makes, but it seemed pretty logical at the time.

Anyway, I was lucky enough to find a dentist who didn’t say a thing to me (I saw a cosmetic dentist–which I highly recommend. My insurance covered him, too). I’m sure he knew — I had 4 cavities — but he just fixed what he needed to fixed and I moved on with my life. It was such a relief.

I’m sure that dentists do see evidence of eating disorders months before anyone else (especially if you do go the recommended two times a year)… but there is a difference between your doctor confronting you about your eating disorder from your dentist doing the same. I’m okay talking about it with my PCP (and even my neurologist — hey, why not), but definitely not about to have a conversation about it with my dentist. I don’t know why there is such a big difference between “you’re hurting your body” and “you’re ruining your teeth,” but the former seems like no big deal and the later feels so shameful.