Sounds like punishment

I ran across this on Junkfood Science this morning. Just what the world needs — another eating plan! This is like weight watchers for kids… eat this many exchanges, write down everything, and go to the groups. It’s not a diet… it’s a “change in lifestyle.”

It’s amazing what you can pass off with the label of “healthy.”

Renfrew’s definition of healthy:

• No food is “good” or “bad.” Everything from pizza to carrots to peanut butter and candy can be part of a healthy menu.
• Eat when you are hungry. Stop when you are full.
• Stay fit by exercising! You can take up a sport or join a class like dance or karate but you don’t have to. Playing with friends can be just as energizing and fun!
• All bodies are different. People of all shapes and sizes can eat well and be healthy.
• Remember that fat does not equal bad and thin does not equal good.

BodyWorks‘ definition of healthy:

• Write things down as soon as possible. Write down everything you eat, even if it’s just one cookie. Be honest. Includes drinks.
• When eating out, the girls are advised to limit fried foods and order the garden salads with low-fat dressings and always pick the low-fat choices.
• Get the smallest serving or sandwich on the menu
• Avoid mayonnaise and use mustard or ketchup because they have less fat
• “try pizza without cheese.”
• Exercise for one hour on most days. “Vigorous active is best for getting and staying fit.” Vigorous was described as so intense you’re “sweating, breathing hard and can’t talk or sing.”

I think that Renfrew’s description is a very “feel good about yourself no matter what” approach and that BodyWorks’ list is probably posted on a pro-eating disorder site somewhere. I can’t help but think that “healthy eating” falls somewhere in the middle.

Group therapy — where to draw the line?

Group Therapy May Help Memory

“Memory lapses could initially be caused by psychological stress. If the memory lapses are noticed, they can lead to anger and fear. Ultimately, this leads to heightened stress levels, which in turn increase the risk of memory lapses. This vicious circle capturing the sufferers is best characterized by models of somatoform disorders.”

So many studies (of different populations) have proven group therapy to be helpful: cancer survivor groups, alcoholics anonymous, grief & lost groups… there is definitely a lot to be said about sharing your feelings, relating to the experiences of others, getting advice, and giving some back.

I thought this article was interesting because of the direct connection between memory and mental illness…

stressor –> anger and fear –> heightened stress levels –> memory impairment

This isn’t really anything new… really post PTSD literature will tell you the same thing. You experience a traumatic event, it is too stressful (stressful can meaning scary, hurtful, etc.) for you to be able to handle/comprehend. You repress (or suppress — that’s another discussion in itself) the memory, but unconsciously/subconsciously it still bothers you. This distraction results in decreased memory function.

The biggest advantage of group therapy? Relating to others’ experiences and understanding more of your own. The biggest disadvantage? The trigger of these relatable experiences and the reliving of your own.

I’ve never been in an ED group that allowed talk about trauma. Even in the trauma groups I’ve been to, details of everyone’s stories have always vague. That’s pretty counterproductive, now that I think about it… discouraging talk about already isolating and taboo subjects… but there was some common understanding that sharing experiences with others could be a bad thing — you don’t want to bring up more trauma issues for anyone. You have to be careful.

I’m not sure how I really feel about those groups or that whole concept, and memory disturbance-causing stressors are probably rarely traumatic events… but how ironic that this treatment proposal is exactly what we were told not to do.

This is the same relationship between my ED treatment experiences and the Maudsley approach. I was always told that it’s not about the food — if you’re talking about the food, then you’re concentrating on that because it’s easier to obsess over that than to deal with more painful emotions. Not that Maudsley doesn’t involve any therapy (not making that assertion at all), but it strikes me as very “yes it IS about the food.”

I definitely keep up on psych research more than anyone I know… but it kinda makes you lose faith in the field. So much is contradictory… it’s not a hard science, so we don’t really know what works.

Maybe you can argue that treatment can be whatever you want it to be (you can definitely argue that different people require different kinds of treatment). I really believe that there has to be some more systematic approach to handling mental illness, though.

Therapists are like Starbucks Drinks

Choosing a therapist these days can be like ordering a drink from Starbucks:

I’ll have a grande CBT lite DBT Gestalt-free psychotherapy with two shots of psychoanalysis and breve IPT.

This image came to mind have after dinner with a friend last night. She’s been in therapy for several years, and has decided to switch to someone with “a little more of a CBT focus… who still integrates interpersonal therapy but spends less time talking about family.” Hmm… good luck with that search, Rach.

The reality of it is, there are so many types of therapy out there. Just to give you an idea of how many:

• Art therapy
• Cognitive-behavior therapy (CBT)
• Dialectical-behavior therapy (DBT)
• Exposure therapy
• Family therapy
• Gestalt therapy
• Group therapy
• Integrative psychotherapy
• Interpersonal therapy
• Hypno-therapy
• Marriage counseling
• Music therapy
• Narrative therapy
• Play therapy
• Psycho drama
• Psychoanalysis
• Psychodynamic psychotherapy
• Psychoeducation

… and on and on and on. Granted, some of these are much more common than others, and you could probably lump a lot of them together, but you see my point — what therapy is right for you?

No one therapy has been proven to be the best choice with eating disorders (especially anorexia), so your perception of recovery and ED etiology will be largely influenced by your first therapist. I think very few people have much information on all of the available types of treatment (not to mention the different kinds of therapists, psychiatrists, social workers, doctors, nutritionists, counselors, etc.). And even if they did… how do you know which therapy to try? And what exactly is the focus of therapy supposed to be? What is the interaction between you and your therapist supposed to be like? How are you supposed to feel when walking out of therapy?

There are so many beliefs in the psych field right now, that maybe you do need to customize your treatment like you would your Starbucks drink. And beyond that, maybe you’ll need to just around between types of treatment… not necessarily because you chose wrong in the first place (although that’s common), but because you have different needs at different times in your life and stages of your disorder.

Where this gets tricky, though, is with the concept of “bad therapy” — and if you’ve read my other posts, you’ll know that I believe that there is bad therapy. Maybe the kind of therapy that you gravitate towards is appealing is because it allows you to perpetuate your disorder or to ignore some issue. You can draw pictures forever in art therapy and never change any eating behaviors. Or, you can talk about your meal plan every single week with a nutritionist and never bring up a bad relationship that you’re in. So, I guess what I’m asking… is to what extent is therapy supposed to be comfortable? Is it no pain, no gain?

Any input would be appreciated…

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Your health problems are all in your head

Being someone with chronic headaches and nausea (probably as a direct result of the headahces), this article caught my attention: Gastrointestinal Problems May Be Associated With Other Health Problems And Even Previously Experienced Abuse

People with recurrent gastrointestinal complaints often have other concurrent health problems, seek medical care more frequently, and experience lower quality of life than those without such complaints. Evidence also suggests that women with gastrointestinal complaints may have experienced various kinds of abuse earlier in life.

While I am all about medicine taking a more holistic approach (maybe the GI problems are a result of allergies, or stress, or an eating disorder, or muscle fatigue, or who knows), I hate when my medical problems are brushed off as psych issues. I’ve never heard the abuse thing before, but it’s frustrating to have medical complaints brushed aside because of an eating disorder history.

First, with my old pediatrician, if my vitals were fine, my weight not horrific, and my EKG clear — then I was fine. I don’t think I was ever asked how I felt. Headaches, stomach aches, tiredness — all obviously because of stress over eating. Knowing about my mental illness history didn’t enhance my treatment, but really rather gave my doctor an excuse to chalk my other complaints up to psych issues.

Recently I’ve seen a new doctor, and during my first appointment she said, “I don’t have any experience with eating disorders and I’m not sure what your doctors have done in the past, but you have these chronic headaches and stomach aches that need attention. I want you to feel the best that you can, and these need to be treated.” I was really stunned, especially since I had just explained to her that the nausea was probably from my calcium supplement and that the headache and stomach ache were just consequences of my ED history. It was really nice to see someone who cared about more than my weight and vitals and who didn’t think the headaches/stomach aches were all in my head.

On a slightly different tangent, one other point in the article:

The results also showed that people with gastrointestinal complaints who seek help at health care centers made approximately twice as many physician visits and calls to the centers as people without such problems. They also obtained more prescriptions and took considerably more painkillers. In addition, they more often had other concurrent health problems.

No, you don’t say — people with stomach pain went to the doctor more often than people without pain? Imagine! And then they took the advice of those doctors and obtained the prescribed medication? Novel. Come on now, this paragraph is basically saying “Sick people go to doctors more than health people, and then they take more anti-sick meds than those who aren’t sick.” I really hope that something more than this revelation came out of the research.

Tags: Eating disorder, anorexia, bulimia, nausea, gastrointestinal problems, abuse, holistic medicine, mental health, mental illness, stomach ache, chronic headaches

Wanting to Want to Recover

It’s no secret that many anorexics are ambivalent about recovery. I remember a period of time when I knew that recovery was the right answer… but I just really wasn’t ready. I wanted to want to recover. I think it’s a tough position to be in.. a very stagnant place to be in. Because you could be receiving treatment (I was inpatient at the time) but still not really feeling it. What do you do then?

This article is probably my second favorite article (my first still being this one on ED diagnostic criteria). There a lot of really important points that I want to highlight…

Controlled Motivation vs. Autonomous Motivation
Controlled being the expectations of others, guilt, shame, punishments, anxiety, etc. Autonomous being personal values and commitment, enjoyment, interest, etc. According to the article,

“…action that results in sustained change occurs only if the change endeavor is autonomously–preferably intrinsically-motivated.”

Essentially, YOU have to want to recover… it’s a personal choice to make recovery-oriented behavioral changes. Others can’t do it for you.

“Motivation to change implies an intention–weak or strong–to change one’s behavior. However, AN patients may at the same time both wish to recover and be highly resistant to change their behavior. Therefore, we suggest that assessment of motivation in these patients should include not only their motivation to change, but also their different wishes to recover which do not necessarily imply a behavioral intention.”

While this probably sounds contradictory upon first read, I think it’s pretty common to want to recover without really giving up the eating disorder. It seems so possible to pick and choose the parts of the disorder that you want: so, you don’t want to feel lonely or depressed, or be cold all the time, or have anxiety attacks… but at the same time you don’t want to gain weight, eat more, or completely stop purging. I can’t tell you how many people I know who’ve tried to recover without gaining weight. So while you’re “in recovery”… eating better, going to therapy, etc.. you’re also only partially doing what you need to be doing.

Motivation to recover:

“Some [patients] described wishes to recover as triggering dramatic changes in the AN behavior. On the other hand, some patients described no behavior changes associated with these wishes.”

“What was the turning point?” and “What will it take for you to see that you’re sick?” are such common questions. For some people, there is that dramatic turning point… usually a medical scare or a realization that you’re hurting other people or throwing your life away. Something that convinces you that the risks are greater than whatever you’re getting from the eating disorder. Some people don’t have this turning point… they can have medical scares, lose all the relationships in their lives, drop out of school–you name it. There’s just this ambivalence… there’s something that’s making you hold onto the ED, and nothing has been important enough to override it.

Higher-Order Constructs:
Joy, spontaneity, choosing to recover, limitation of goals, etc. … I could probably talk about each of these, but the post would be much too long. I was really happy with the inclusion of self-knowledge:

“Self knowledge” includes experiences of understanding oneself better. Being able to know better who they were, their needs, what they liked, and which experiences had been significant in their lives, could make them feel more content about themselves.”

What’s so tough about self knowledge? Well, it’s as if you lose yourself when you’re in the thick of the disorder (think of the phrase, “That’s not you talking — that’s your eating disorder talking”). It becomes your identity. Unfortunately, the longer you’re sick, the more of your identity that it becomes… you cut off relationships, quit hobbies and extra-curriculars, and stop thinking about anything but food. I sometimes think of inpatient says as a revolving door — you continue to go in and out of hospitals because it’s become your life. You’re spending your time with nutritionists and therapists, talking with all your ED friends from previous inpatient stays, behind in classes or work because of the time you took off to go inpatient, etc.

It is really hard to rebuild your life without the eating disorder identity. You have to re-figure out what you like, what you’re good at, and how you interact with other people. You’ve gotten all of this attention because you have been sick, and you don’t want to completely lose that. You need to find something else that makes you feel like you are enough… so that you don’t need the eating disorder as an excuse or punishment or something to hide behind.

Social Supports:
Throughout this paper, there are numerous references to family and friends in the context of recovery.

“Joy” refers to the experiences of being happy and glad when engaging in an activity or being together with people.”

“Informants could meet other people who confronted them directly with their need to make an active choice about their own recovery. Such people could be their docto, therapist, family members, and others whom informants trusted.”

“Other people expressing their worry about the patient’s health could alert her to the face that she suffered from a worrisome disease.”

“Because these women were preoccupied with what to eat and when to eat, they had much less time to make new friends and be with friends and family. They missed their social life and felt depressed and lonely.”

You need other people to recover. I believe that so much about eating disorders is about relationships… and that new relationships can have an amazing impact on recovery. Other people can’t make you get better… but having people around to support your recovery efforts, model normal eating, show you that you’re cared about without the ED, and provide some accountability — I think that that can make the difference between wishing to recovery and actually making progress.

Tags: Eating disorder, eating disorder diagnosis, anorexia, bulimia, recovery, eating disorder recovery, eating disorder treatment, self knowledge

Chronic Anorexia and Personality

From a study on perfection and anorexia:

Levels of perfectionism stayed the same while eating disorder symptoms and psychiatric symptoms decreased during recovery. Levels of perfectionism were inversely related to duration of remission so that individuals that had short illness duration had lower levels of perfectionism at both follow-ups. Patients with initial high levels of perfectionism may be at risk for a long illness duration which we recommend clinicians to acknowledge.

I am personally very interested in “chronic anorexia” — which is a controversial topic, since some believe that all eating disorders are life-long illnesses (like addictions — even when you haven’t had a drink in 30 years, you still haven’t recovered) and others believe that everyone can recover and that there is no difference between a “chronic anorexic” and any other anorexic.

I fall somewhere between the two camps — I think some people have chronic eating disorders and others do not. I believe that there is an inherent difference… possibly a genetic difference. Maybe compare it to depression — some people have Major Depressive Disorder, and others have one depressive episode in their life (which could be largely situational). Some people really do have a chemical imbalance that requires them to be on medicine for life, while others can take SSRIs for 6 months and be okay. At some point, depression is depression… but I really think you’re dealing with two different beasts.

The word “risk” really speaks to chronic anorexia. I feel that people with some degree of an ED history are forever at risk. Not everyone, but those with chronic EDs — yes, forever at risk. This article shows that there are underlying differences — in this case, a personality trait (perfectionism). It’s not just about the food, bad body image, or your even your familial relationships and childhood experiences… it’s this underlying risk. Because of who you are — your genetic predisposition, personality, and comorbidities — you are always at risk. Not that you can’t get better and live a normal life — but you have to be conscious.

Tags: Eating disorder, anorexia, chronic anorexia, bulimia, perfectionism, recovery, eating disorder recovery, mental illness

Therapy should come with a warning

7 Challenges of Psychotherapy

1. It can take awhile to find the “right” therapist and you shouldn’t stop at Therapist #1.
2. Therapy is a strange, unnatural combination — an extremely personal, intimate relationship in a professional setting.
3. Therapists leave and therapy ends.
4. It’s only 50 minutes a week.
5. Sometimes a friend will work just as well.
6. “Side effects” of psychotherapy are unpredictable.
7. Therapists can be just as crazy as any of their clients

This is by far one of the best articles that I’ve read lately. It directly addresses one of my biggest pet-peeves — the illusion of psychotherapy as some cure-all for mental illness. People take this “well, therapy can’t hurt” approach to treatment. Not true! The quality of the “therapeutic alliance” is the best predictor of treatment success.

Why do I think therapy is tough? Well…
1. It takes forever to find the right therapist for you. Heck, it takes awhile to find the right approach to therapy (CBT? DBT? IPT? Psychoanalysis? Gestalt?), let alone a therapist who you click with!

2. You can only have problems at 4:00pm on Tuesdays (or whenever your weekly session is). Okay, so you can just talk about all the other days during the week that you struggled… but rarely do you have an appointment when you need it the most.

3. Opening up and trusting a therapist requires a significant leap of faith — especially when half the people are going to therapy because are either depressed (and cutting themselves off from other relationships in life) or seeing a therapist because they have trust/relationship issues.

4. At least with eating disorders, the “Do I deserve help? Am I sick enough to deserve help? Does she actually care about me? Will she care about me if I get better? Am I only worth caring about when I’m sick?” questions are killer. How is treatment supposed to be successful when you have to be sick to receive help?

5. When you really start to develop and good relationship, then the person that you want to talk to the MOST is your therapist… which sucks, since she’s only accessible at 4:00pm on Tuesday.

6. So you finally talk about how abusive your father was when you were little, cry, and completely fall apart for 50 minutes… and then you’re supposed to go back into the real world and be A-OK? …Really? If you’re talking about stuff significant enough to be contributing to/causing your mental illness, then you’re probably going to be less okay leaving the your therapist’s office than when you went in.

7. Since there are so many different therapeutic approaches, different therapists will tell you different things. Therapist A thinks that your mother is overprotective, which is now driving your need to control your life through food and weight. Therapist B thinks that your mother was protecting you from your abusive father, and that your eating disorder is an attempt to be more like your mom and less like your dad. Etc. etc. (I could come up with these scenarios forever…). Who do you believe? Well, you generally believe whoever you’re seeing at the time (assuming you trust your therapist and want her help).

8. You have one therapist — your therapist has three dozen patients. Remembering that you’re just another one of the many people she talks to is hurtful.

9. Ending therapy is a nightmare for anyone with abandonment issues (read: 50% of all people in therapy). The only time I’ve had no trouble ending a relationship with a professional was when we didn’t get along in the first place. Even if you’ve moved past your original problem, systematically ending such a close relationship is just unnatural.

Do I think that therapy is helpful? Yes, usually. Do I think that therapy can be counter-productive? Absolutely. Aside from all of the reasons listed above, there are several of dangers of therapy:
a) Re-traumatization
b) Disturbing existing functional relationships
c) Sick syndrome — the attitude that you are sick and are therefore excused from XYZ. You can’t help XYZ because of your disorder (and your therapist told you so).
d) Learned helplessness – from Wikipedia: a psychological condition in which a human being or an animal has learned to believe that it is helpless in a particular situation. It has come to believe that it has no control over its situation and that whatever it does is futile. As a result, the human being or the animal will stay passive in the face of an unpleasant, harmful or damaging situation, even when it does actually have the power to change its circumstances.
d) Apathy (you can only explain your life story so many times)

… and, the biggest danger of all: Starting to talk / think like a self-help book.

I've heard Prozac is in the water, but not Over The Counter

This article came out last week, but just caught my article today: Prozac Over the Counter? – TIME

The article makes some great points, so I definitely recommend reading it… but I of course have to give my two cents.

Why do I think that Prozac should NOT be OTC?  Well, my biggest concern, is that depressed individuals who would take OTC Prozac would not seek the help that they need — and they may very likely need MORE help than just an SSRI.  It’s hard to seek mental health treatment — while depression has become so common these days, there’s still a stigma attached to it.  If you could just go to the drug store and pick up some antidepressants, then you don’t have to take that first asking-for-help step.  Suicide rates are going to rise, because so many cases of depression are going to go unreported.  And this isn’t because they’re going to take the OTC Prozac and feel better — it’s because they’re going to think that a Psychiatrist can’t do any more for them.

Pills don’t make problems with psychological components go away. Take diet pills for example — they clearly have not ended the obesity epidemic or cured people suffering from binge eating.  They have caused a lot of heart attacks, though.

Do I think that it should be hard to get antidepressants?  No.  Do I think they should be basically free?  Yes.  (and Prozac practically is at Walmart!  Still waiting for the day when Wellbutrin is on the $4 med list… the day may never come…)  I do think it should SSRIs should stay prescription, though, because I think that someone should be somehow monitoring you at least a couple of times a year.

I’ve heard Prozac is in the water, but not Over The Counter

This article came out last week, but just caught my article today: Prozac Over the Counter? – TIME

The article makes some great points, so I definitely recommend reading it… but I of course have to give my two cents.

Why do I think that Prozac should NOT be OTC?  Well, my biggest concern, is that depressed individuals who would take OTC Prozac would not seek the help that they need — and they may very likely need MORE help than just an SSRI.  It’s hard to seek mental health treatment — while depression has become so common these days, there’s still a stigma attached to it.  If you could just go to the drug store and pick up some antidepressants, then you don’t have to take that first asking-for-help step.  Suicide rates are going to rise, because so many cases of depression are going to go unreported.  And this isn’t because they’re going to take the OTC Prozac and feel better — it’s because they’re going to think that a Psychiatrist can’t do any more for them.

Pills don’t make problems with psychological components go away. Take diet pills for example — they clearly have not ended the obesity epidemic or cured people suffering from binge eating.  They have caused a lot of heart attacks, though.

Do I think that it should be hard to get antidepressants?  No.  Do I think they should be basically free?  Yes.  (and Prozac practically is at Walmart!  Still waiting for the day when Wellbutrin is on the $4 med list… the day may never come…)  I do think it should SSRIs should stay prescription, though, because I think that someone should be somehow monitoring you at least a couple of times a year.