“A relationship doesn’t have to be romantic to fall into the “toxic” category, of course. Many friendships, mother-daughter, boss-employee, and waiter-eater relationships qualify. If someone is bringing you down consistently, chances are that your relationship with him is toxic.”

Hmm, sounds like something that I can connect to eating disorders! (Imagine!). I’ve heard that “the eating disorder is like a bad boyfriend.” I guess that in this context, referring to the eating disorder as “Ed” makes a lot of sense. The boyfriend analogy aside, the eating disorder does fall under the category of “toxic relationship.” Just look at how relevant the 10 steps are…

1. Step out of denial - I just wrote a whole post about eating disorders and denial. The article suggest asking yourself questions like, “Does the ED leave you feeling energized or drained? Do I want to spend time on the ED or do I feel like I have to? Do I look to the ED for a response that I never get?”
2. Keep a log of emotions – I’ve had a hundred food journal variations, but I think they all had a section for thoughts and feelings.
3. Identify the perks - The eating disorder is doing something for you… it serves a purpose (maladaptive as it may be). Maybe it’s something you’re good at, or it’s a distraction from everything else in your life, or maybe it numbs overwhelming feelings. There are pros of the eating disorder.
4. Fill the hole - EDs are coping skills. If you take it away, you have to find some other coping skill to rely on. (See my whole series on coping skills). Recovery might leave you with other holes… like free time that you previously spent obsessing over food/weight or that sense of accomplishment that you got when the number on the scale went down.
5. Surround yourself with positive friends - the article is right on with this one:
   

   “Lots of support and friends isn’t going to cut it. You need the right kind of friends – i.e. those working on their boundaries as hard as you are, who aren’t enmeshed in their fair share of toxic relationships and therefore become somewhat toxic themselves. The stuff is contagious.”

   Eating disorders are competitive. Dieting and disordered eating are prevalent in society. It’s easy to be triggered and important to be surrounded with “normal” eaters.

6. Drop a note to yourself – I was glad to see this on the list, just because it makes me feel a little less crazy. I write notes to myself all the time.
7. Bribe yourself - I knew a girl who did this. When she was tempted to binge, she’d take the money that she wanted to spend on that and purchase something else for herself (nothing big – like $10 to $15).
8. Heal the shame - I think that shame is HUGE in maintaining eating disorders. The article references “inner-child work,” which I know is helpful for a lot of people.
9. Repeat affirmations - I am not an affirmation person, but I may be the only one. However, I am a QUOTE person… and while not really the same as an affirmation, I think that they can kind of serve the same purpose – to cheer you up, keep you motivated, remind you of something important, etc.
10. Allow some rest - need I really elaborate?

So, while I don’t think I’ll be telling my friend that my eating disorder is just like his relationship with his girlfriend… it’s an interesting idea.

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…

“Addiction is the only disease that you have to convince people that they have.”

I highly disagree with this statement, and think that denial is a large part of many mental illnesses… and even some physical illnesses. Just to name a few:

• eating disorders
• personality disorders
• depression
• ptsd
• dementia

Sometimes people just don’t want to admit that they’re struggling with a mental illness (maybe they think it means they’re a weak or defective person). Sometimes people feel their issues aren’t severe enough to warrant a diagnosis. “I’m not depressed — I’m just in a negative funk.” Some of this probably has to do with the stigma and stereotypes of people with these diagnoses. You always think of the most severe cases. With anorexia, you think of an adolescent girl who’s emaciated and never eats, ever. With depression, you think people who never leave their house and cry all the time or are suicidal. With PTSD, you think rape or child abuse or something horrific. You end up comparing your symptoms with those on the far end of the disordered spectrum… and then of course you feel like you’re okay! There’s also the misperception that you can’t be sick and be functional in life. You can be both awesome at your job and still very disordered.

Denial and minimization are hallmarks of eating disorders. There are probably a thousand different reasons why, but to name a few:

• not feeling “sick enough”
• still functioning in everyday life — maybe you’re even very successful in other aspects of life
• weight is not extremely low (maybe it’s even normal or above)
• still eating (or keeping food down) sometimes
• you have previously been much sicker & are comparing current symptoms to those during the height of your disorder
• “everyone has somewhat disordered eating”
• “I am healthy enough”
• all-or-nothing thinking — you have one or two good days and feel that you are therefore fine
• fear of having to change

One difference between addiction and eating disorders, is that you are forever a recovering addict (at least that’s the most popular ideology). You can be sober for 40 years, and you’re still a recovering alcoholic. With eating disorders, you can jump all over the diagnostic landscape. There’s switching between disorders, periods of recovery, relapse, and maybe full & sustained recovery. Because of this, you may have to be convinced a dozen times in your life that you have an ED. And, with the line between normal and disordered eating being so fuzzy (diet food… disordered or not?), it can be hard to tell whether or not you have an issue.

Convincing someone that they have an eating disorder can be a long, frustrating, and repetitive process. I’m very biased, but I’d even venture to say that EDs take more convincing than addictions.

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.

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.

This evening I was reading Carrie’s post on overcoming core traits.  Personally, her post was very timely, having just finished reading the book, “When Perfect Isn’t Good Enough.”  That is NOT a book that I would normally pick up (I feel pretty well-versed in perfectionism), but my therapist handed it to me.  In hindsight, maybe I could have NOT read it and argued that I was challenging my perfectionism by not doing my therapy homework.  Oh well, next time…

Anyway, the book made a lot of good points, and I could write a dozen posts on it (maybe I will… another day), but one thing that really stuck out for me was the idea that perfectionistic behavior maintains perfectionistic beliefs.  I understand the whole idea of challenging perfectionistic beliefs and testing their validity – that wasn’t really a new concept for me.  What I am curious about, though, is if perfectionistic behavior can exacerbate perfectionistic beliefs, and therefore anxiety?

A year ago, I switched jobs to something that required a lot of persistence and focus to detail.  A LOT.  How perfect – I can get paid for my OCD-like tendencies!  When the job opportunity arose, I really approached the career change from a square block, round hole perspective.  Instead of trying to be less perfectionistic, I could just switch to a job that encouraged it.

After reading this book, I’ve started to wonder if my meticulous work makes my anxiety worse.  I can (and sometimes do) agonize over details all day.  I’m always engaging in perfectionistic behaviors.  Is that impacting my beliefs?  And do those beliefs influence other areas of my life?  Instead of work being an outlet for the OCDness, is it just making those tendencies worse?

I like my job and am not about to change that, but it’s an interesting thought.  Does perfectionism breed more perfectionism?  Even accross life domains?  Hmm.

The introduction contains the best definition for “coping” that I’ve seen to date:

Coping refers to the thoughts and behaviors that people engage in so as to manage, tolerate, or reduce internal or external demands that are appraised as exceeding an individual’s resources and is typically thought of as a factor that mediates the relation between stress and the onset of psychiatrist illness.  Coping is often depicted as a multi-dimensional construct, including task-, emotion-, and avoidance-oriented skills.

The whole article is definitely worth the read (and you can download the whole text for free), but there were two things in particular that I found interesting:

1. The healthy controls had the highest level of avoidance-oriented coping skills
2. Partially-recovered individuals were closer to those with active eating disorders, while fully-recovered individuals coped more similarly to the healthy controls.

The avoidance finding was a pleasant surprise (for me).  I’ve always believed that avoidance is a healthy coping skill to some extent… but have had therapists who insist that it is maladaptive.  The article makes a good point about this:

[Avoidant] strategies can be effective in the short-term for reducing pain, stress, or anxiety, and can include some adaptive strategies (e.g., spending time with a special person or going for a walk…)

The second finding about partially-recovered vs. fully-recovered was also validating to see.  The only distinguishing criteria between fully and partially-recovered individuals was the presence of psychological recovery.  I think that sometimes in treatment, individuals can be deemed “recovered” even when they are still struggling with a lot of the old, destructive thoughts.  Personally, I have found this partially-recovered stage to possibly be the toughest.  You’re not using your eating disorder to cope and you don’t have the level of care and/or support as you did at the height of your disorder, but you’re still struggling psychologically.

There are lots of other great points made in the article, so I highly suggest that you take a look!

I could not, would not, on a boat.
I will not, will not, with a goat.
I will not eat them in the rain.
I will not eat them on a train.
Not in the dark! Not in a tree!
Not in a car! You let me be!
I do not like them in a box.
I do not like them with a fox.
I will not eat them in a house.
I do not like them with a mouse.
I do not like them here or there.
I do not like them ANYWHERE!

I do not like green eggs
and ham!
I do not like them,
Sam-I-am.

–Dr. Seuss

There are more than a dozen interpretations of “Green Eggs and Ham” out there (just google it, you’ll see), but I’m pretty sure that mine isn’t one of them. When I hear the rhyme, I think of all the rules that individuals with EDs have surrounding food. Sometimes we’ll get a new patient who is not going to eat the meal if any of the following are true:

• One food is touching another food.
• Something requires a spoon.
• The food can’t be picked apart or cut into tiny pieces.
• There are caloric drinks (milk, juice, etc).
• Something is “not warm enough.”
• A piece of fruit has a spot on it (even a microscopic spot).
• The food can’t be eaten in a particular order.
• The room is too hot or cold.
• She’s sitting at the end of the table.

…and I could go on. I will definitely confess to doing some of these things. I hate juice and/or milk. My point is, though, that said new patient is against eating the food here, there, or anywhere. She’s wrapped up in the eating disorder and not even considering any of the above.

While I totally sympathize, part of me can’t help thinking “Well…. actually, you will eat your green eggs and ham – and you’ll (learn to) like it.” That’s kind of how treatment is. You come in screaming, “No no no! I will not I will not I will not! Not in a box or a house or even in the dark!” And you learn (or slowly realize) that not only are you going to eat them in the dark, but with a goat in a tree while it rains as well.

I re-watched Girl, interrupted the other day.  When I first saw the movie, I was in high school had just gotten home from my first ED inpatient stay.  The film actually made me homesick for the treatment center and all the girls there.  I was amazed at how well the directors portrayed the relationships and lives that are formed in an inpatient setting.

Anyway, now that I’m a little older and detached from the inpatient thing… I can appreciate the pure GENIUS that is this movie.  Maybe I’m exaggerating little bit, but there are so many little nuances that you probably can’t appreciate if you haven’t been inpatient before.

For example…
Susanna’s mother drove her to the psychiatrist’s office, but Susanna had to take a cab to the treatment facility – because “it will be less emotional that way.” That’s such a treatment thing to say.

Susanna’s parents took her to psychiatrist’s office.  Her psychiatrist told her she had to go for treatment and got her a cab.  The cab dropped her off at the front door of the treatment facility.  The nurse met her and walked her into the place.  And then… she is told that she has to sign the papers because she’s choosing to be there.  It is just like that!  Yes when you’re over 18 and not being committed, you are technically choosing to be there… but in this scenario, it doesn’t really feel optional and it was definitely not your idea.  They should change the words.  Instead of saying “you are choosing to be here,” they should say, “you are over 18 and not being committed.”

During the initial tour, Susanna and Valerie find Polly in the art room by herself – where she’s not allowed to be. Coming from the real world you’re thinking, “She’s not allowed to be in a room by herself?  What is she, three?”  It’s similar when you’re touring an ED facility and they are explaining that the bathrooms are locked and that you have to ask for permission to use them or count while you are in there.

Valerie tells Susanna that in a month she’ll likely have grounds privileges, and Susanna balks and says she’s not even supposed to BE there that long. That has definitely happened to me!  They told me I would have probably have exercise privileges in three weeks, and I explained that I was only STAYING three weeks total.  And I got that same kind of “okay then, don’t worry about that now” nod that Valerie gave Susanna.

Everyone always wants to know the others’ diagnoses. I think that’s normal human curiosity, and since everyone is in there for SOMETHING… While ED treatment centers are a little more dichotomous than general psych units, you still want to know what ED they have.

The first family session with Susanna’s parents starts with her mother describing a situation where Susanna rolled off the bed when she was changing her diaper. The trauma!  It’s all of the stereotypical “causes” wrapped up in one: blaming the mother, everything relating back to an incident in childhood, parental neglect or abuse…

Also in the first family session, the psychiatrist mentions mental illness being more common in individuals with a family history of mental illness. He may have well said, “maybe something is wrong with one of you, too.”  In ED intake assessments, they also ask about family history – and it makes sense.  They have to.  However, I think things start to get uncomfortable when the therapists start to ask about the parent’s eating habits and parenting skills.

Susanna isn’t told something about her diagnosis because it could “hinder her recovery.” Thankfully this is LESS prevalent now, but it still exists!!  Especially with personality disorders.  I’m not sure how NOT knowing your diagnosis would help your recovery, but would love to hear someone’s opinion on the matter.

They all went and got ice cream in a blizzard. I found this particularly funny, since more than once my dietitian has wanted to do an “ice cream challenge” in the winter.  We’ve never done one in the summer.

I’m sure that there are a 100 more nuances in the movie, so if you think of any, definitely comment!

“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.