I’ve been trying to figure out what it is that bothers me about having them there.  I’ve looked up the nutrition facts a hundred times, so it’s not like I’m seeing the calorie count for the first time.  Plus, I still ordered the same thing (hey, I’m a creature of habit).  Still, I didn’t like the calories being there.  I have a couple of theories as to why…

1. Out of sight, out of mind – I know how many calories are in an asiago cheese bagel.  I know how many exchanges it counts for toward my meal plan.  However, I’m not really thinking about it when I order, because I order it all the time.  It’s a “safe” food for me.  The calorie reminder is not helpful — it makes me re-examine my choice.  I stop thinking “I’ve eaten this a dozen times and have been fine, therefore it’s still fine” and start thinking, “hmmm, you know, that is kind of a lot of calories for a bagel.”
2. Comparisons — When you put all the items in a list, I can’t help but compare the calories.  Somehow strawberry cream cheese doesn’t seem like such a good idea when I’m comparing it to the lower-cal plain cream cheese.  I start looking for the “best” choice.  There’s just something about lining them all up that enables me to do that.  It’s harder to choose the strawberry cream cheese when I have the calories of all the different kinds in front of me.
3. Ignorance is bliss — Okay, so I don’t know the calorie content of all the items on Panera’s menu–just the ones that I usually get.  I really had no idea what was in a Sierra Turkey Sandwich (I’m a vegetarian).  Let’s say that pigs flew and that I did order it one day, though.  I’d know that foccacia bread was higher-calorie than whole wheat bread, sure.  However, I wouldn’t know exactly how much of a difference it made.  If I did, there’s no way that I would ever get it.  I understand that this is probably the whole point of the new menus — to make consumers aware of what they’re ordering so that they can make educated decisions about sandwiches.  Well, educated / disordered.
4. Obsessing – I don’t really need any help (or encouragement) obsessing over food, calories, etc.  Seeing the calories while I’m ordering just puts me in the wrong mindset.  I’m thinking about calories instead of exchanges, for one.  And once that’s happened, it’s hard for me to figure out what I want.
5. Calories aren’t the end-all, be-all – It’s actually kind of interesting to me that Panera chose to just display calories.  Granted, that’s probably the most universal measure of food okayness, but these days the diet industry seems to be all about carbs and/or sugar.  So yeah, a blueberry bagel may have fewer calories than the power breakfast sandwich, but it doesn’t have nearly as much protein as fiber.  And sometimes, I actually consider those other factors.

As someone recovering from anorexia, I know I’m in the minority of Panera customers.  I don’t expect them to cater to individuals with eating disorders.  Do I think non-ED people will change their orders based on the new menus?  Probably for some, but I really don’t know.  I’d be curious to see how many people order the Sierra Turkey Foccacia Sandwich now.  Maybe having calories in menus isn’t that different from having nutrition labels on packaged foods.

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 haven’t read the study yet (I will!), but every blog post and newspaper article I’ve read so far focuses on a few things:

• eating disorder tips/tricks
• thinspiration
• promotion of anorexia as some kind of elitist lifestyle choice
• sick poems, art, music, etc.
• advice on hiding the disorder from friends/parents and avoiding food

It’s true that all of this exists and is unhealthy.  Sure.  However, if you were to analyze the traffic on these eating disorder websites, I bet you anything you’d find that only a SMALL percentage of one’s time is spent looking at “thinspiration” or reading some anorexia-glorifying poem.  Rather, people frequent these sites because of the forums — and that’s becuase they are using the forums for support.

And I mean serious support.

On many of the sites, it doesn’t matter if you’re in recovery, anti-recovery, or have never even thought about it.  You can complain about anything – how guilty you feel for “not restricting enough” today, how isolating it is to not have your school friends understand, how upset you are over breaking up with your boyfriend, how fearful you are that  your nutritionist is trying to make you fat, etc.  I really doesn’t matter what you talk about, other people in these communities are going to support you.  They’ll tell you that tomorrow will be better, or you actually hardly ate anything, or that they’re worried about you and are glad you ate more.  Someone will be able to relate to your boyfriend situation, your run-in with your dietitian, or your recent argument with your parents.

Individuals start to get all of their social support from these communities… which means not only are they getting some really unhealthy “advice,” but it also means more and more of their time is being spent in this eating disorder world.  Even if you can talk to your parents or school friends, they likely don’t understand at the level as the other girls on these forums do.  Or, if you are in treatment, what other support is available at 2am?

I’m not supporting pro-ED sites (or non-anti-ED sites…. if that makes sense) at all, and don’t want this post to be mistaken as such.  Of course I think they are harmful.  However, I don’t think that the “thinspiration” or ED “tips” that are the most concerning aspects of these sites.  You can find a picture of Mary-Kate anywhere.  It’s much harder to come by a friend who will support your disordered thoughts and behaviors.  That’s what keeps people active in unhealthy ED communities, and I think that’s a much more complicated issue to address than the photo galleries and static “how to lie to your parents about eating” pages.

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.

First WHAT!? moment:

Participants were asked how the decision had been reached to avail of their various treatment options. Most participants had no involvement in any decisions pertaining to treatment.

WHAT? No way, I don’t believe that. I think there’s a BIG difference between treatment not being your idea and having “no involvement in any decisions pertaining to treatment.” I highly doubt that every person in this study was court ordered or dragged kicking and screaming into the treatment facility. Most of the people in the study were diagnosed in adolescence, so okay, maybe they HAD to go then… but the participants also all had “a lifetime history of AN.” As an adult, they CHOSE to get treatment. Even in Intervention (the TV series), you are given a choice — either get help or live a really difficult life where no one in your family will support you anymore. It probably doesn’t really feel like a choice, but it still IS one.

I know I’m fussing over semantics, but not taking ANY personal responsibility for your health / illness / treatment is a pet peeve of mine. I’ve had my fair share of anti-treatment periods, and can definitely separate the times I wanted help versus the times I didn’t, but the reality is that I DID show up for that doctor appointment. Maybe she “made” me go, but I could have immediately signed out. Staying in treatment is a decision.

Second WHAT!? moment:
(when talking about deciding factors for dropping out of treatment)

while for three participants (15%) the fear of weight gain was a major contributing factor to dropout.

Only 15% of patients would say that the fear of weight gain contributed to their decision to drop out / sign out of treatment? That’s just not honest. If everyone created a pros/cons list when considering quitting treatment, I bet that weight gain would be on 75% of their lists. Maybe it’s not in the top 3 reasons for leaving, but probably most patient’s top 10. Personally, I might not admit to my professionals that it’s a contributing factor, because I’d want to sound reasonable, rational, and believable (and definitely not want it to sound like a decision motivated by my eating disorder). Also, maybe I should clarify this is a list for dropping out of treatment — ending treatment because you’re ready or your team is ready to discharge you is different.

Anyway, I encourage everyone (who can get it) to read the article, and have a lot of other thoughts on it, but these few statements really stood out for me tonight.

While I’m not in a position where I have to calculate hours spent on a task, I was thinking about how the eating disorder would affect my focus factor.  It’s kind of scary (and pathetic) when you really think about how much of your time the eating disorder can consume.  Obsessing about your weight, what you’re going to eat, what you already ate (etc) is really distracting.

I tried to break down the components of my focus factor, and came up with the following pie chart:

Eating disorder-wise, this isn’t really current for me.  I’d say the numbers are accurate for when I’m struggling moderately — not at my best or my worst.  When you add it all up, I’m really only focused on work for 1/3rd of the time I should be working (this isn’t including the rest of the non-work day).

One time when I was struggling, I cut back my work hours to do day treatment.  I fussed about what a disaster it was going to be to not be getting work done.  I was afraid I’d be letting my coworkers done and hurting the overall quality of my team’s work.  As it turned out though, by getting more treatment I drastically reduced the amount of time I spent on all those ED thoughts and ended up being MORE productive.  Go figure.

My therapist still loves to bring it up, in some kind of “remember how you are actually more productive and successful when you make treatment a priority?” comment.  While it’s definitely true, I knew I shouldn’t have admitted it…

Your problem is you’re… too busy holding onto your unworthiness. – Ram Dass

As someone who’s struggled with an eating disorder for longer than I would like to admit, I’ve definitely had periods of falling into the “I suck at recovery” trap.  It connects directly to the “I am wasting everyone’s time and don’t deserve help” trap as well as the “I’m actually fine and asking for too much because I’m attention-seeking like that” trap.  And let’s not forget the “It’s not fair that my family / friends / husband / dog have to deal with my having an eating disorder” trap.  I have a complex and well-developed network of traps, apparently.  Kind of like dig dug.

What happens is that I get SO CONCERNED that I’m asking for too much help or am burdening everyone so much that I don’t actually make any progress in treatment.  Because, what if I’m crying wolf and don’t actually have an eating disorder?  Then making progress in therapy is irrelevant because it’s not like there’s anything to treat in the first place.

My problem during these periods is exactly as the quote describes:  my preoccupation with my unworthiness for help keeps me stuck.  I need to stop obsessing over whether or not I’m too needy and just get it through my head that I still need therapy.  THEN we can actually do something therapeutic.  Nothing productive comes from holding on that “I don’t deserve help” idea.  Doing worse or not telling my therapist anything for fear of “burdening her” probably just causes more frustration for everyone.

I know I’m not the only one who struggles with this, because I see it all the time with friends.  I’m sure it’s something worth exploring in therapy — why do you feel unworthy?  However, I also think it’s the result of a lot of arbitrary expectations and “shoulds” — that there’s a maximum length of time you should be in treatment, or fixed amount of help that you should need.  Using that logic, when you exceed those two years of therapy (I’m completely making that number up), it means you’ve worn out your welcome in the treatment world.

The other idea that I get from this quote is the security of holding onto the “I’m not good enough” idea.  My therapist would tell me that I hold onto the unworthiness thing because it’s easier to make myself the “bad” one than to admit that people around me couldn’t/didn’t meet my needs… and maybe that by continuing to hold onto the idea, I’m protecting myself from being let-down again.  I don’t know about all of that, but I do know that being in the “I not worthy / deserving / needing of” trap does definitely keep you stuck.

Anyway, while discussing Bob Forest, we decided that we wouldn’t want to have to hunt patients down when they left treatment AMA.  Do addiction counselors really do that?  It’s TV-rehab, so I’m guessing probably not, but I have no experience in this domain so I don’t really know.  I can’t say I’ve ever seen a psych professional ever go searching for a patient, though.  In fact, I’m pretty sure it would be viewed as inappropriate.  I’m trying really hard to envision the ED-version of Bob’s driving into the dessert to get Heidi back into treatment… but I’m having a hard time imagining my dietitian (or therapist, or anyone else) driving to my house (or local laundromat?) to make sure I didn’t skip lunch.  It would never (even in a million years) happen.

There are lots of things that professionals do in Celebrity Rehab which I’ve never heard of before:

1. Actually going out and finding patients that leave treatment AMA.
2. Having patients stay at your house for a night if they leave sober living.
3. Have your house re-decorated while you’re in treatment.
4. Going to the veterinarian with you if you have to put your dog down.
5. House calls (or hotel, in Seth’s case) to visit former patients and convince them to come back to treatment.
6. Setting up random activities to help patients find themselves (ballet lessons for Mary, a benefit concert with School of Rock for Mike)

Just to name a few.  Again, I know it’s VH1 and not exactly “real life,” but wow — where can I find a treatment center that will redecorate my house while I’m gone?

Note (05/02/2010): I’ve updated the mind-map to a) remove the typo and b) make it bigger for printing purposes.  Click on the image to load the larger diagram.

It has occurred to me lately how often I say “I don’t know” in my appointments (possibly even more often than I say “I know” !).  My therapist has come to totally disregard the phrase, which for me, has become very versatile:

Type 1: the how-did-you-feel-in-that-situation “I don’t know”
Usually used when discussing some childhood event that I kind of remember.  I could probably figure out how I felt about it, if I spent some time thinking about it, but I really don’t want to… so off the top of my head I don’t know.

Type 2: the I-do-know-but-I-don’t-want-to-tell-you “I don’t know”
There are lots of reasons why I might know and not want to say anything….

1. I don’t want to analyze it, and I know that my therapist is going to
2. I’m embarrassed
3. I don’t have the energy to get into it at that moment
4. I just don’t feel like telling her

Type 3: the can-this-conversation-end-already “I don’t know”
This “I don’t know” is often accompanied with a lot of “uh huh”s, “yeah”s, and “mmhmm”s.  Saying anything besides “I don’t know” is going to continue the conversation, which I definitely do NOT want to encourage.

Type 4: the I-don’t-believe-you “I don’t know”
Usually a response to a statement rather than a question… when I’m being told that taking care of myself is important and it’s okay to ask for help and I’m not too needy, and all of those other things I have a hard time believing.

Type 5: the I-want-you-to-tell-me “I don’t know”
Okay, sometimes I test my therapist, and sometimes I just want to be told things.  I know what I think, I’m bored with my answer, and I want a professional’s perspective.

…you know, the more I think about this, the more types I can come up with.  Maybe I should just make a mind-map:

Take the DSM-IV and add water.

Basically the new system expands each eating disorder category to be more inclusive, therefore reducing the percentage of sufferers in the EDNOS category.

How do they suggest doing this? Well…

1. decrease the specificity of each diagnostic category
2. remove concrete diagnostic criteria
3. rely primarily on clinical judgment for diagnosis

I think that by broadening each eating disorder type, they are creating more heterogenous patient populations.  Isn’t this a major criticism of the EDNOS diagnosis that they are trying to resolve?  I’m all for being more lax on the 85% of IBW rule (your diagnosis shouldn’t change just because you gain to 88%) and the frequency of binge/purge episodes, but as I said in my last post, diagnoses are meant to guide treatment.  Even from just a medical perspective, the anorexia diagnosis implies certain hallmark concerns – anemia, osteoporosis, low blood pressure, refeeding syndrome, etc.  Physicians know what to look for.  Research can be more accurate.  I think there are identifiable types of EDNOS patients and they should be classified as such, rather than getting lumped into another diagnostic category that only kind of fits.

I also take issue with their increased emphasis on clinical judgment:

“This scheme also offers an advantage for diagnosing individuals with eating disorders outside of specialist settings, where a comprehensive psychiatric assessment may not be feasible (e.g.. primary care)”

PCPs already often miss eating disorders… even with defined criteria and many present symptoms!  How will removing guidelines going to help them better diagnose patients?

What else bugged me about the study?  Well…

1. Individuals with a “lifetime eating disorder diagnosis” were excluded from the study
2. Course of illness, treatment approach, and treatment outcome were not considered
3. Anorexia was declared the most serious type of eating disorder, and therefore has the “highest position in the hierarchy.”
4. Diagnoses require significant functional impairment
5. Individuals are lumped into broad categories based on just BMI and functional impairment.
6. No definition of “recovery” or guidelines for when a patient is ready to end treatment.

I feel like this system takes current issues in eating disorder research, diagnosis, and treatment, and magnifies them.  Issues like specificity, chronicity, and the definition of “recovery.”