“If you tell the truth, you don’t need to remember anything.”

– Mark Twain

“I don’t ask why patients lie, I just assume they all do.”
“It’s a basic truth of the human condition that everybody lies. The only variable is about what.”
“I’ve found that when you want to know the truth about someone that someone is probably the last person you should ask.”

– Gregory House

So, while everyone lies sometimes, people struggling with an eating disorder (or addiction, or probably other mental disorders) lie more. It’s the nature of the disorder — you lie to others and you lie to yourself.

Mark Twain’s quote made me think about my own truth, though. Sometimes I think that I lie to myself so much, that I don’t even remember whether or not it’s the truth. Or maybe it’s that I can’t identify what is or isn’t true? And, as odd as that sounds, I think that’s kind of the goal of avoidance — isn’t it? To pretend and ignore things that you don’t want in your reality. You convince yourself that you don’t care, that it didn’t matter, and that it didn’t really happen.

In therapy, you run into that lying combination (to yourself and to others). It’s confusing enough when you’re just lying to yourself… but when you’re really into your disorder and your lying to professionals, to, it just gets MESSY. For the sake of this post (because I am sure I can think of more), let’s say there are four types of lying:

Lying to yourself:

1. Rationalizing with myself to the point where I’ve convinced myself it’s not actually true.
2. Not being able to gauge or recognize whether or not something is significant.

Lying to others:

1. Omitting information
2. “Real lying” (as I like to call it).

Lying to myself:
By the time I get to my therapy session, I really do feel “fine.” Maybe I had the worst weekend ever, but come Tuesday I’m thinking “oh, it was okay, and that was so two days ago.” Sometimes I don’t even remember significant events until my therapist brings them up. I can say (and pretty much believe) that eating went pretty well, until she asks something specific… like “how about that dinner you were really nervous about on Friday?” Oh, yeah……. THAT dinner…. forgot about that one.

Lying to others:
While lying to yourself creates plenty of chaos around determining what’s actually true, lying to others makes it 100 times more complicated. You can probably sense my personal definition of “lying” just by my distinction between “omitting information” and “real lying.” So, let’s say in that same therapy session, I failed to mention that I kind of quit taking my medication (and by “kind of,” I mean I did). It didn’t come up in the conversation, and she’s not my psychiatrist, so….. It’s easy to rationalize. And, as for “real lying” — well, I probably don’t even have to come up with an example of that one.

You can see how managing this information becomes increasingly difficult with each session. You’re struggling to determine if you really did have a bad day last week and to remember if you admitted to acting on symptoms in your previous session. It just doesn’t work well.

Personally, it’s much harder for me to stop lying to myself than it is to be truthful with others (and that’s including all the “positive” reasons that I do lie to them — wanting to protect them, not wanting to be a burden, decreasing worry, etc). With myself, determining the “truth” is this multi-step process. I have to determine whether or not I’m upset… then identify what is upsetting me and whether or not I do actually care about it. From there, I have to decide whether or not I’m going to acknowledge (let alone ADMIT to my therapist) that whatever event didn’t feel or go okay. It’s such a… process.

Summary:
If I had planned a takeaway message from this post, it would be this:

I think that a lot of the same principles that Mark Goulston points out can apply to mental illness in general. A few of them really stood out to me:

Failure to develop new and healthy relationships
I see this two ways:

• Old relationships – maintaining unhealthy relationships (people who drag you down in any way, bad influences, people who don’t respect your boundaries, triggering people, etc) is just going to keep you sick. Good things just aren’t going to come from perpetuating bad relationships.
• New relationships – In treatment, I think you have to be careful about the friends that you choose. With eating disorders, people are competitive and hanging out with others can be triggering. With that said, it’s also really validating to find individuals who can really relate and understand what you’re going through. So… just be careful that your new friends are good influences.

Trading addictions
I see this all the time! Changing from bulimia to anorexia is not recovery! And how many people pick up smoking while trying to kick another addiction? Tobacco companies should stop marketing to teens and target the addiction crowd (really, it’s that prevalent).

Self-deception
I think this is even a bigger problem in EDs than in substance addictions. There is no abstinence from food, so it’s easy to think you are “healthy enough.” It’s a really foggy, zig-zag line between disordered and healthy. Skipping one meal is not the end of the world… nor is over-eating on occasion. It’s easy to tell yourself that, too.

Failure to develop meaningful life goals
This is not exclusive to addictions, eating disorders, or other mental illness. I think that feeling like your life has a purpose is key to living a satisfying life. Personally, not feeling like I am doing anything significant or fulfilling is a significant part of what keeps me stuck in my ED.

Anyway, I highly recommend that you read the original article with all 10 “cracks” in the recovery process.. Dr. Goulston does a great job of highlighting the red flags.

A lot of Meredith’s monologes hit home with me, but she said something the other day about surgery and recovery that really hit me:

“The goal of any surgery is total recovery – to come out better than you were before. Some patients heal quickly and feel immediate relief. For others the healing happens gradually, and it’s not until months or even years later that you realize you don’t hurt anymore. So the challenge after any surgery is to be patient. But if you can make it through the first weeks and months, if you believe that healing is possible, then you can get your life back. But that’s a big if.”

Maybe the ultimate goal of treatment (for eating disorders, addictions, depression, anything really) is total recovery… but I think most people would tell you that intense treatment doesn’t immediately fix things. You don’t go to intense treatment and come back cured — it’s not that black and white. However, what I think people don’t realize is that treatment and recovery doesn’t even feel good a lot of the time. It can be miserable. Maybe there is some immediate relief at the beginning of treatment… usually because you’re pretty miserable in your disorder/addiction and knowing there’s help and a light at the end of the tunnel is some much needed hope. I knew a girl (in treatment for anorexia) who said the first month of intense treatment was easy, just because she was so hungry and tired of restricting. I can understand that.

My experience has been that much of treatment is uncomfortable. You’re pushed past what you’re okay doing and your negative coping skill of choice is taken away. Doing better can feel so much worse. How much does that suck?

I think Meredith is right on when she says “if you can make it through the first weeks and months, if you believe that healing is possible, then you can get your life back.” You might feel miserable during treatment. You might feel even worse immediately after intense treatment, when you’ve dropped levels of care and are dealing with the real world without your eating disorder / addiction. After a few months go by, though, it doesn’t feel so awful. That hurt and misery fades.

In the moment, the uncomfortableness feels so permanent. Unbearable, maybe. But, I think if you can keep plugging away… being patient with yourself, giving yourself some grace, and really just giving recovery a chance… it will get better. Maybe the word “healing” sounds so soothing and therapeutic… but like with surgery, that post-op period just isn’t fun. However, it’s also not permanent.

Tracking food:
I still track food exchanges (well, sometimes), and originally I could only find one app that was appropriate for this in the app store: EatRight.  After that I discovered Foobi, and most recently have converted to FoodTrackerPro.  Note: none of these apps use calories — just servings/exchanges — and I’ve been pretty pleased with all of them, but FoodTrackerPro is definitely the coolest.  PLUS, it works on the iPad, so bonus points for that.  You can customize your meal plan and make charts and set goals and all of that… but it also has a great food servings cheat-sheet — for all those times that you’re trying to remember how much hummus equals a protein exchange (for example).  iPhone/iPad, $1.99.

Tracking mood:
I started doing this on paper awhile ago and found that it was actually a good exercise for me (not only to see the patterns in mood but also just to check in with myself).  I’ve seen several apps for this, but currently my favorite is MyMoodTracker (same company as FoodTrackerPro, actually).  It’s only for iPhone (no iPad yet, bummer), but it tracks mood using a 1-10 scale and little emoticons.  You can track sleep on here, too, and see how that influences mood.  iPhone, $1.99.

Meds:
You know those times when you’re at the drug store trying to purchase something to help with your nasty cold, and you can’t remember if it’s okay to take Sudafed with the Wellbutrin you’re on?  That’s when you need Epocrates.  Or… when you have a headache and have already taken Tylenol twice and are not sure if it’s okay to take another dose yet?  Okay, maybe it’s just me, but I run into situations like this all the time and would be lost without this app! Plus, when you’re on more than one med at a time (which is pretty common these days), things get complicated (drug interactions, dosing, side effects, etc), and it’s just good to have it for reference.  iPhone, free.

Countdown:
By now you’re probably thinking, “okay, you track way too many things”–and it’s probably true.  BUT, do you know what’s even better than personally tracking something?  An app that does it for you!  That’s Countdown.  I have countdowns for everything — how long I’ve been married, how long it’s been since I last acted on symptoms, how many days until my next therapy appointment, how long until my birthday (hey, why not….), etc.  Random countdowns aside, there’s something really motivating for me about knowing that I haven’t skipped a meal in three months, or drank coffee since…. err, yesterday (okay, really bad example), or that I have therapy in 1 hour, 42 minutes and 18 seconds (and really need to do my therapy homework).  I just love seeing that.

Coping Skills:
Remember my series on coping skills?   Well, for each of those items, there is of course an app for that:

1. card stores – it’s not a card store, but someecards can entertain me for an embarrassingly long period of time (both the app and the website).
2. bulletin boards – Corkulous would probably by my favorite app-equivalent of a regular cork bulletin board.  However, the real purpose of bulletin boards for me are to serve as reminders, so that the “out of sight, out of mind” thing doesn’t kick in.  For that, I’d probably actually use a todo app or custom background/wallpaper (not going to link these because there are a million and I don’t have a favorite!)
3. kudos chart – again, this is something you could probably find in a todo app, but if you’re looking for something a little more…. sticker-chartish… try GoalTracker (ipad).
4. crafting — there are a million apps for: coloring, collaging, drawing, photo-editing… really, a million. You might start looking in Apps for Kids.
5. dvds — you can download just about anything from tv/dvd onto your iPhone/iPad from the app store.  Additionally, ABC has an awesome media player that lets you stream shows for free.

Okay, that’s the end of my list for today.  If anyone has any other app suggestions, I would love to hear them!

I can definitely relate to this. When you first start a higher level of care (like IOP, PHP, IP – anything involving a meal), the amount of food you have to eat (and keep down) is a little overwhelming. At the same time, there’s a little bit of relief that comes with eating at program. You don’t have to make the decision of what to eat yourself. You really don’t even have to take any responsiblity for eating. The meal is structured, dietitian-approved, and you could spend the next couple of hours processing the horror of the meal if necessary (although hopefully not).

While thinking about this, I decided that there are four stages of eating in treatment (in this sense):

1. Eating at program is really hard. It’s more food than you would eat on your own (or not purge). You’re struggling with acting on symptoms at home, and meals at program are much more “normal” and overwhelming than you’re used to.
2. Eating at program is still hard — but for a different reason. You are actually starting to eat more normally at home, and it really feels like too much when combined with all the food at program. You feel guilty for not compensating (or not purging).
3. Eating at program is easier. This is because
             a) you’re used to the meals by now
             b) you’re taking food risks at home (eating fear foods, going out to eat with friends, challenging food rituals, etc.)
   The food at program feels reliable and safe in comparison.
4. Eating at program is boring — and even annoying. You’ve eaten a veggie burger every week for two months and feel that you could go the rest of the year without eating yet another yogurt. You would rather be eating at home — not because you want to restrict, binge, or purge, but because you want to eat something better (that you actually like) or be eating with other people.

I could probably come up with more stages, but these four are the most obvious to me. I’d love to hear your thoughts…

1. Feeling your feelings – good, bad, and everything in between
2. Your body adjusts to where it needs / wants to be (based on your own genetics)

Johanna supports these two ideas with a lot of great thoughts, so I definitely recommend that you read the post.  However, what really caught my eye was one of the comments:

My therapist told me yesterday that “people try to get out of their eating disorder by going into their eating disorder.” I slipped a little in the past two days. My therapist said, “You’re in the hole, but you’re trying to get out of the hole by going farther in the hole. You don’t climb out of a hole by going down. It’s like people are hoping so hard that if they just go farther into the hole, they’ll find a secret back door that will let them out more easily. The truth is, there is no back door. It’s a cul-de-sac. It’s painful to be in the hole, and it’s painful to come out of the hole. But there is only one way out. Up.”

Laura so eloquently articulated something that’s going to take me five paragraphs to describe.  Everyone has heard the phrase about things having to get worse before getting better.  However, it doesn’t say MAKE things worse so that they can get better.  It doesn’t exactly work like that.  I see a couple of different situations where people “try to get out of the eating disorder by going [further] into their eating disorder”:

1. Trying to replace one symptom with another
2. Not feeling “sick enough” to recover
3. Waiting to hit rock bottom
4. Trying to do recovery perfectly

To explain a little further…

Trying to replace one symptom with another
Replacing bingeing or purging with restricting is not recovery.  Replacing restricting with compulsive exercise is not recovery.  It’s tempting to say, “okay, I’m going to stop bingeing and eat only healthy food and lose weight.”  I think this just exacerbates the binge > purge > restrict cycle.  It seems unintuitive… but I think part of the recovery process is learning to forgive yourself when you do screw up.  It’s being a little more lenient with yourself… not stricter.

Not feeling “sick enough” to recover
I’ve blogged about this several times.  There’s the whole “if I were really sick, then I would recover” idea.  Or “if I just lose 5 lb., then I’ll feel ‘sick enough’ and will feel justified in trying to eat more and get better.”  There is no “sick enough,” though.  Digging a deeper hole is not the answer to getting out!

Waiting to hit rock bottom
This is the “I’m still functioning, it’s not THAT bad” rationalization.  Or the “I’ve been worse before” idea.  There doesn’t have to be a rock bottom.  While true that some people have that moment when something really awful happens and makes them realize they are ruining their lives and have to change, I’d say those individuals are more the exception than the rule.  I’ve had “rock bottoms” (note the plurality), and sure, they motivated me to change.  However, the times that I really committed myself to recovery were not near those bottoms!  I’m very guilty of the “I’m a functioning person so I’m fine” excuse.  I have to stop and remind myself, “Why would I want to wait until I lose my job, ruin relationships, have a heart attack, etc.?  Can’t I just avoid that horrible bottom and work on getting better now?”

Trying to do recovery perfectly
I know so many people who want to keep “restarting recovery” so that they can “do it right this time.”  Restating seems to imply getting worse… so that you’re back at the starting line to try again.  I’ve done this over and over with eating and my fear of having a slow metabolism forever.  If I’m not following my meal plan, yet maintaining my weight, I am convinced that I screwed up in the recovery process somewhere and am condemned to a life of having to watch my weight because I’ll obviously gain eating a normal amount of calories.  And then, what’s the solution?  To lose weight, of course… so that I can try that again and follow my meal plan and trust the science of it all.  When you’re deep in the eating disorder, it seems to make a lot of sense.  But, looking at it from the outside… why would I think that doing worse would be the solution to getting better?

Laura summed this up so well: You don’t climb out of a hole by going down.

While this probably sounds depressing, I actually think that the idea of remission is very validating. It gives you another shade of gray in the sick to healthy spectrum. Plus, I think there’s a fear (and hence a danger) that comes with the idea of being completely recovered. While recovery suggests, “You’re done! It’s over! You are cured, have a nice life!,” remission leaves the door open. To me it says “You’re doing great right now, but come back [to treatment] if you need to in the future.”

When you have been declared recoverED, do I think that you are less likely to go back and get treatment if things start to go south in the future? Absolutely. I mean heck, you recovered! The eating disorder is over. With remission, there’s more of a “okay, this is acting up again, I should do something about it” feeling. The relapse could be just as significant in either case, but it feels more reasonable to ask for help in the second case.

Diagnostic Crossover in Anorexia Nervosa and Bulimia Nervosa:
Implications for DSM-V
(Am J Psychiatry 2008; 165:245–250)

I actually think this whole study was amazing and definitely recommend reading it if you can (and I’m always a skeptic, so this is rare that I’d say this).  That said, I don’t think that the study does much for defining, validating, or invalidating the ED-NOS diagnosis.

 I think that this is brilliant, and should be used for actual diagnosis… not just as a measure in this study:

The Eating Disorders Longitudinal Interval Follow-up Evaluation was used to assess symptoms at intake and to assign DSM-IV-TR diagnoses during the follow-up period.  This instrument yielded weekly psychiatric status rating scores (ordinal, symptom-oriented scale scores based on Research Diagnostic Criteria ratings) for anorexia nevosa and bulimia nervosa for each participant.  Psychiatric status ratings range from 0 to 6 for anorexia nevosa and bulimia nervosa, where:

0 = no history of the disorder

1 = a past disorder with no current symptoms

2 = residual symptoms (e.g., minor eating disorder cognitions without current behavioral symptoms)

3 = partial symptoms (i.e., does not meet for criteria)
    e.g., for anorexia nervosa is ≥ 90% ideal body weight with significant cognitive symptoms
    e.g., for bulimia nervosa, experiences binge eating and/or compensatory behaviors 1 – 3 times a month with significant cognitive symptoms

4 = marked symptoms (just misses full criteria:
    e.g., for anorexia nervosa is >85% ideal body weight with significant congitive symptoms
    e.g., for bulimia nervosa, experiences binge eating and compensatory behaviors 4 – 7 times a month

5 and 6 = full criteria, depending on symptoms severity or degree of impairment
    e.g., for anorexia nervosa, a 5 would indicate ≤ 85% ideal body weight, and a 6 would indicate ≤ 75% ideal body weight.
    e.g., for bulimia nervosa, a 5 would indicate binge eating/compensatory behaviors 2+ times a week, and a 6 would indicate daily binge eating/compensatory behaviors.

DSM-IV-TR diagnoses were assigned as follows:
AN, restricting-type = Max AN psychiatric status rating ≥5 and max BN rating ≤2.
AN, binge eating/purging type = Max AN psychiatric status rating ≥5 and max BN rating was ≥3.
BN = BN psychiatric status rating was ≥5 and max AN rating was ≤4.

Partial recovery = max status rating was for both AN and BN was 3 or 4.
Full recovery = max psychiatric status rating for both AN and BN was ≤2.

I really think that their psychiatric status rating could be a huge asset to DSM-IV diagnosis.  There is a lot of discussion about mental illness (in general) as a continuum, rather than clusters of individually-defined disorders.  This study proposes a continuum within a specific diagnosis.  This seems like a great way to approach it, since a big criticism of the continuum theory is diagnostic specificity.  Diagnoses are necessary for treatment (and research).  Moreover, the scale eliminates the confusion between sick, in recovery, in remission, and fully recovered.  You could have a diagnosis of ANR-1: anorexia nervosa, restricting type, recovered but with a history of the disorder.  These disorders can affect your health decades after the height of the illness, and this ANR-1 note would be useful to future physicians.

As an individual, I think it feels much more validating to have an ANR-#, ANP-#, or BN-# diagnosis.  You could be IN a treatment facility and cross over that 85% body weight mark… and suddenly not qualify for the disorder anymore.  With treatment centers often treating physical symptoms before mental/emotional issues, I think that this psychiatric status rating would be a much more accurate diagnosis.

Tags: Eating disorder, eating disorder diagnosis, psychiatric status rating, DSM-IV, chronic anorexia, eating disorder recovery