Category Archives: eating disorder recovery

Food is Not a Moral Issue

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“I’m being naughty today”, the woman in front of me paying for her coffee and brownie says to the cashier. I grit my teeth and bite my tongue. I want to tell her that the word “naughty” does not apply to food. I wanted to tell her that being naughty is doing something wrong, and food is not a matter of right and wrong. I wanted to tell her that food is not a moral issue.

“I’m treating myself today” is another one I hear often when in the queue at coffee shops; the women looking guiltily at the cashier, wanting to justify their hesitant decision to buy a slice of cake. The underlying message is always “I’m disciplined usually! I swear it’s just this one time! I don’t usually eat cake!” And underneath that, is the belief that cake is bad.

How can a food be bad? It doesn’t make sense when you really think about it. Food fits into the category of inanimate objects. They are not alive, and do not possess a personality or a concept of right and wrong. Food cannot be good, and it cannot be bad. Food is food. Food provides energy, and different types of nutrients dependent on the type. Eating one type of food doesn’t make you good, and eating another type of food doesn’t make you bad. It just means that you are eating a food type. Having cake does not have an impact on your morality, and therefore, neither the cake nor you are bad.

Bad, indulgent, naughty, sinful – these are all words to describe a personality or moral status, and yet we – and the advertisements that we watch – use them to describe some of the foods that we eat. Why only certain types of food? Who decided that cake, chocolate, or ice cream was indulgent or sinful? Who came up with the idea that eating a burger is bad? Who suddenly felt that consuming a bag of crisps was naughty?

But what about gluttony? you ask, gluttony is one of the sins. If you are of a certain religion, then you’re right: gluttony is, in some Christian denominations, viewed as a sin. I also want to point out that, according to the Bible, wearing two types of material together is a sin, as is divorce, eating shellfish, and your wife defending your life in a fight by grabbing your attacker’s genitals (no seriously: “If two men, a man and his countryman, are struggling together, and the wife of one comes near to deliver her husband from the hand of the one who is striking him, and puts out her hand and seizes his genitals, then you shall cut off her hand; you shall not show pity.“). We seem to over-exaggerate some “sins” and ignore others entirely to suit our society. Gluttony – derived from the Latin “gluttire” (to gulp down or swallow) – means to over-consume food, drink, or wealth items to the point of extravagance or waste. Note that it is not limited to food and is about the immoral actions of wasting food or wealth that could be given to the needy. Note again how it does not specify certain types of foods and is not related to weight or healthy but rather to greed – having so much that it goes to waste. That does not mean eating a piece of cake because you fancy one. It means buying two cakes, eating to the point of nausea, vomiting so that you can fit in more, eating again, and throwing away the rest. (In this example I want to make it very, very clear that I am not talking about vomiting as an eating disordered behaviour. Vomiting to fit more food in was something that historically was used by wealthy citizens so that they could continue to eat more when extremely full, and I would imagine is linked to how gluttony was historically viewed in its accurate portrayal rather than our ridiculous twisted version of “gluttony” in our diet culture orientated society).

Even when I’m aware of all of this and have a healthy and happy relationship with food, it is still sometimes near impossible to not become sucked into the feeling of shame for buying foods that are considered “bad” in our diet culture, even though I myself do not feel that way. Standing in the queue at a store, chocolate in hand, I have felt anxious that I might be being judged for my choice of purchase. This is heightened by the fact that I am not someone who is super slim, and people are far more likely to judge those who are not super slim for their food choices than those who are. This type of judgement becomes more prominent the bigger the body – which is utterly inappropriate and stems from the incorrect belief that food and weight are intrinsically linked and that those who are bigger should eat less or differently to those who are smaller (check out my section on set point theory under “links” for more information), so I dread to think of the way those without any kind of thin privilege might feel at the prospect of being harshly judged for buying chocolate and the like.

I was talking with a friend recently about how people feel they have to behave in a society like ours in regards to food and exercise. My friend, for your information, is the epitome of the “ideal” woman that our society says we should strive to be: a blonde beauty: very slim but with curves in all the “right” places, but she is not exempt from the multitude of insecurities that our society pushes upon us. You can be the “ideal”, and you are still not ideal enough, and that is how the diet and weight loss industry makes billions of dollars per year, because we are always striving to change our body and make it “better”. She says, “I can be dressing up to go out on a night out, and I will have the same amount of insecurities as someone else [with a completely different body type] – they are just different insecurities about different things.”  In our second year of university she was miserable, and on reflection, she now puts a lot of that negativity down to the fact that she was forcing herself to go to the gym and eat salads, just because she felt that was the “right” thing to do. She was restricting her body in the name of being “healthy” and being “good”, when in actuality she was starving her body and subsequently destroying her emotional state at the same time. She has no history with an eating disorder in any shape or form, and even so, our diet culture told her that what she was doing was “right” – something she continued to do for the majority of that year, in spite of  both mental and physical effects.

The message our society gives out about food is toxic and damaging. Start trying to repair your relationship with food. It’s okay to eat what you want, when you want. You do not have a moral obligation to eat in a certain way (the same applies to exercise). Don’t label foods as “healthy” and “unhealthy” (read: “good” and “bad”), as this perpetuates a negative and unhealthy relationship with food. Enjoy your food. See it as a wonderful thing that provides for your body, brings people together, and gives you pleasure.

Food is food. Food is not a moral issue.

Distinguishing Your Voice From that of Your Eating Disorder

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Recovery can be really hard when you are unable to distinguish the eating disorders “voice” from your own. Making decisions becomes an uncertain task that can end up taking up far too much of your time because you are anxiously torn between what you want and what your eating disorder wants, and not being able to tell which is which. Because the voice actually sounds like your own thoughts, this can make it really difficult for someone to tell what thoughts are really theirs, and what are those of the eating disorder.

When it comes to telling your voice and the eating disorder’s “voice” apart, the first thing to think is “do I really want this?” Some people are able to quite easily separate the two with just that first question, and others are still unable to do so.

When it comes to food, and choosing to eat a certain food or comparing between two choices, the easiest way to tell what it is you want is to ask yourself; if it had no calories, would you really want to eat it? Or would you prefer something else? If the two you are comparing to had no calories, which one would you actually want to eat more? Another thing to do is think, if I walked away with this one and bought it, would it give me more anxiety than the other option? The one that you have more anxiety over is the one your eating disorder wants you not to choose, and is therefore the one you should choose to confront and overcome that anxiety. I would bet that the other one is something your ED picked to get you to choose that “safer” option rather than the one you really want to eat.

When it comes to negative thoughts about yourself – that’s not you. Hands down anything negative that comes into your head will be your eating disorder. I say this because now, in remission, I rarely have negative thoughts about myself or my body. When I do, they are quite mild and I can tell that they come more from a “normal” brain and have developed because of the society we live in. Negative thoughts caused by an eating disorder are usually very forceful, very malicious, and very hateful. They are cruel comments, not just “hmmm I’m not sure I’m loving those back rolls but meh okay what was I doing let’s carry on with that.” They are hurtful, vindictive, venomous comments like “you are disgusting” or “you are worthless” or “you are a worthless fat bitch”. When you experience thoughts like that, they are the lying, bullying voice of the eating disorder and you need to recognise that that voice does not carry truth. It just wants to hurt you. I would place my bets on saying that 99.999% of negative thoughts going on in the head of someone with an eating disorder are eating disorder thoughts.

When you are eating, or buying things for yourself, or doing something you enjoy, etc etc, and a thought comes into your head about not deserving to eat it, or buy it, or do it, then that is not your own thought. That again, is a bully inside your head that should not be there. Kick it out. Tell it that it is wrong. You deserve all the things that you want and you should be able to have all of the things that are within your reach.

When it comes to negative thoughts or thoughts that you don’t deserve something, ask yourself “is that something I would say to someone else?” If it isn’t, chances are it’s your eating disorder speaking. The things that eating disorder says to us, we would not find it acceptable to say to others, or let others say it to us, but we let that internal voice say it to us and submit to it. Start changing that and fight back. Recognise that the “voice” is just playing on your insecurities and is making unacceptable and vile comments towards you. Tell it to f*** off.

When it comes to other habits or behaviours, for example using certain items of cutlery, using certain plates or using only bowls to eat out of, challenge that. If you feel like using a bowl, use a plate. If that invokes anxiety in you, then using the bowl is a disordered habit. Use  a different fork/knife or spoon. If that invokes anxiety in you, then using certain items of cutlery is a disordered habit. The same goes for every habit or behaviour. Test out if they are disordered by switching things up. If you find it hard to sit still or sit down, but are pretty sure you’re just an active person, have a duvet day. If you eat at certain times because, you know, that’s just how it is, make it earlier or later. If you avoid white carbs because you just never really have the urge to eat them, make up a nice crusty roll or a bowl of pasta or some egg fried rice using white products. If you are eating low fat yoghurt but are pretty sure you just love it, buy some full fat yoghurt. Stop making excuses and just do it. It won’t be a problem if it is not a disordered habit. If the change freaks you out, the habit or behaviour is disordered.

These are some ways for you to tell apart yourself from your eating disorder when it comes to decision making and making the choices for you instead of your eating disorder. These tactics, of course, are not exclusive. I would welcome any comments to this post suggesting other ways for people to distinguish between their eating disorder “voice” and themselves. The more the better.

Why You Need More Calories than the Government Approved Recommended Daily Allowance

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We all know the recommended daily allowance of calories that the government has handed us, but do you know where those amounts originate from? Do you know enough about it to trust that those are your energy needs? Because I’m telling you now, you shouldn’t.

I would recommend reading Gwyneth Olwyn’s ‘MinnieMaud Method and Temperament Based Treatment‘ and ‘I Need How Many Calories?!!‘ for an extensive and in-depth analysis of how the RDA guidelines came about, and why they are so inaccurate – complete with references. However, I understand that, although sound in science and reason, many people do show doubt in Your Eatopia and want more evidence: to which I would say, look up the references! Regardless, I am going to write this shorter article in less detail to illustrate why we all need more than that magic RDA.

The recommended daily allowance set by the government came about by using surveys that relied on self-reporting. This means, in short, that members of the population filled out the survey and the results were averaged out. The actual results were above what the RDA is now:

The FDA wanted consumers to be able to compare the amounts of saturated fat and sodium to the maximum amounts recommended for a day’s intake–the Daily Values. Because the allowable limits would vary according to the number of calories consumed, the FDA needed benchmarks for average calorie consumption, even though calorie requirements vary according to body size and other individual characteristics.

From USDA food consumption surveys of that era, the FDA knew that women typically reported consuming 1,600 to 2,200 calories a day, men 2,000 to 3,000, and children 1,800 to 2,500. But stating ranges on food labels would take up too much space and did not seem particularly helpful. The FDA proposed using a single standard of daily calorie intake–2,350 calories per day, based on USDA survey data. The agency requested public comments on this proposal and on alternative figures: 2,000, 2,300, and 2,400 calories per day.

Despite the observable fact that 2,350 calories per day is below the average requirements for either men or women obtained from doubly labeled water experiments, most of the people who responded to the comments judged the proposed benchmark too high. Nutrition educators worried that it would encourage overconsumption, be irrelevant to women who consume fewer calories, and permit overstatement of acceptable levels of “eat less” nutrients such as saturated fat and sodium. – Marion Nestle (from here)

In short, the results came up as an average of 2,350 calories, and even though that has been shown to not be enough for the average man or woman, they still went and lowered it to 2000. We also know that people under-report what they eat for numerous reasons: not knowing the accurate calorie count of food, missing out liquids and condiments, and reporting what they think they should be eating, rather than what they are eating. Even without mentioning that information on the subject of under-reporting, the NHS has written that the calorie guidelines have been underestimate by 16% due to revaluation of people’s average physical activity, including walking, breathing, and even sleeping.

To put it even more into perspective, the RDA for children aged 5-10 years old is 1800 calories. That’s for small children. When you look at that logically, growing teenagers and fully developed adults are clearly going to need significantly more than that.

Although it does not say what the calorie intake was for either groups, in one interesting study, where they studied the eating of healthy, everyday women, they found that those that were eating in an unrestrained way were eating 410 calories on average more than those who ate in a restrained way, and had a relatively lower weight, which feeds into the relatively well-researched theory that eating less actually can cause you to gain more weight due to a decreased metabolism.

When we talk about teenagers, researchers conducted a study involving more than 200 children between the ages of 8 and 17, and used a lunch buffet to give them access to unlimited food. They found that boys routinely eat more compared to girls of the same age, but the amounts that both parties ate do not fit with the RDA that they are supposed to follow. They found that boys in their mid-teens ate an average of 2,000 calories during the lunch hour, which they thought made most sense due to the age that puberty hits most boys. Their calorie requirements appear to shoot up drastically in late puberty (between the ages of 14 and 17). They found that with prepubescent children, the boys averaged nearly 1,300 lunchtime calories, compared to 900 among girls. Girls consumed the most calories during early- to mid-puberty (between the ages of 10 and 13), as they tend to have their most significant growth spurts during that time. Girls consumed an average of 1,300 lunchtime calories.

A study of teenage girls between 16 and 17, where 204 were dieters, and 226 were not, showed that “the mean reported energy intake of the dieters was 1604 kcals/day compared to 2460 kcals/day amongst non-dieters”, and that “more than twice as many dieters as non-dieters failed to achieve the reference nutrient intake (RNI) for retinol equivalents, thiamin, riboflavin, folates, vitamin B12, vitamin B6, zinc, copper and selenium,” which is obviously not healthy at all and suggests that consuming a low intake results in not being able to get enough of what the body needs, both in energy and in nutrients, because the body requires a much higher level of both. There was a similar study conducted on teenage boys.

Now you might say: yes but these studies show that on average unrestricted eating then leads women to need around 2500 calories on average and men to need 3000. Well, yes, those over 25, whose bodies have stopped growing and developing and so no longer need so much energy, do. But those below 25 still need 3000 and 3500 respectively, as their bodies need additional energy to grow and develop. Do remember here that the two studies above on teenage boys and girls are again, self-reported studies where the unrestricted eaters ate 2460 (females) and 3064 (males) – and as Gwyneth Olwyn points out, under-reporting can range from 2% to 58%, and that “if we average the studies reviewed by JR Hebert and his colleagues, then people eat on average 25% more than they think they do (or report that they do).” Also keep i mind that normal, healthy, energy-balanced people do not know the accurate calories in foods, which is why under-reporting can occur in healthy people, and the healthy intake can then be reported as lower than it is because they are going by what they perceive to be a healthy amount, which is constructed by our society in the form of the daily recommended allowance.

And there we have come full circle.

These intakes (2500 for women under 25, 3000 for women under 25 and men over 25, and 3500 for men under 25) are guidelines but best seen as absolutes during the recovery process due to the nature of the eating disorder and the way it will use grey areas to eat less than needed. If your own individual body requires, as a 30 year old woman, 2300 calories, then a extra few hundred calories will not mean that you gain a significant amount of weight more, if any at all, due to the fact that our bodies are able to get rid of energy by burning it off when it is not an excessive amount more than it needs (which would only be consumed by force feeding when you had reliable hunger cues – this does not include making yourself eat when you have unreliable hunger cues), and when you did eat intuitively when fully recovered, any excess weight would be lost again. Any small increase in weight past set point for a small period of time would be far more desirable than under-eating and remaining both physically and mentally ill.

As a p.s. I just want to put a study in about pregnant women and their energy requirements, as this is sometimes a question I receive on my blog. It reports that “in the normal-BMI group, energy requirements increased negligibly in the first trimester, by 350 kcal/d in the second trimester, and by 500 kcal/d in the third trimester.

I would also like to refer you to Wikipedia’s list of how many calories on average people consume in each country.

Refeeding Syndrome in Restrictive Eating Disorder Recovery

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This is an extremely important post for those recovering from a restrictive eating disorder, so please take notice of this, as many of those recovering from REDs are unaware of RFS.

A lot of the text below is taken from the MARSIPAN: Management of Really
Sick Patients with Anorexia Nervosa (October 2010)
. It is very wordy so I took the most relevant parts to bring to your attention, but you can click the link above for the entirety of the MARSIPAN Guidelines. The text from MARSIPAN is referenced as so.

Firstly, I am going to share with you a simplified version of what refeeding syndrome is and how to recognise it.

Refeeding syndrome symptoms may occur when a person receives a large intake of carbohydrates following a period of starvation.

A severe shift in electrolytes takes place when an individual consumes a quantity of complex carbohydrates after a prolonged period of food deprivation. This in turn, causes fluid imbalances in the body, leading to the potentially fatal conditions of hypophosphatemia and heart failure.

Hypophosphatemia refers to an abnormally low concentration of phosphates in the blood stream. This is linked to the transport and cellular uptake of phosphorus and potassium due to excess insulin secretion. Refeeding syndrome symptoms arise when the malnourished person no longer needs to utilize stored fat and protein, and instead metabolizes carbohydrates. The resulting rapid discharge of insulin causes the drop in serum phosphate, producing the clinical symptoms of refeeding syndrome.

Unfortunately, certain early signs of refeeding syndrome may go undetected as they are somewhat unspecific. However, symptoms such as generalized weakness, seizures, muscle fibre breakdown, white blood cell dysfunction, low blood pressure, respiratory failure, arrhythmias, cardiac arrest, and sudden death have all been documented as part of this serious and even fatal syndrome.

Refeeding syndrome symptoms can be of concern to those recovering from eating disorders such as anorexia, as they are at risk of developing hypophosphatemia when starting to eat again. Medical supervision and monitoring by nutritionists and other health professionals familiar with this condition can help improve the outcome for those individuals struggling to re-gain normal eating behavior. (from here)

Below I share information that goes into far more detail in regards to refeeding syndrome, taken from the MARSIPAN guidelines, and the online Nursing Centre – this is quite complex and detailed information regarding refeeding syndrome in a hospital setting.

Re-feeding syndrome is a potentially fatal condition (World Health Organization, 1999; Winston et al, 2000; Crook, 2001; Casiero & Frishman, 2006; Mehanna et al, 2008) that occurs when patients who have had their food severely restricted are given large amounts of food via oral or nasogastric re-feeding as well as during TPN. It has been noted in outpatients with anorexia nervosa who have suddenly increased their food intake after several weeks of starvation. (MARSIPAN)

For example, someone who has been almost nothing could decide to recover and start eating a regular amount of food straight away. Their serum phosphate level could then fall dangerously and require oral phosphate supplements to correct this abnormality.

Electrolyte disturbances (primarily decreased levels of phosphorus, magnesium, or potassium) occur immediately upon the rapid initiation of refeeding-commonly within 12 or 72 hours-and can continue for the next 2 to 7 days. Cardiac complications can develop within the first week, often within the first 24 to 48 hours, with neurologic signs and symptoms developing somewhat later. (from here)

Re-feeding syndrome is characterised by rapid reductions in certain electrolytes, such as phosphate and potassium, caused by rapid transport into cells, and the resulting cardiac effects can be fatal. Avoidance of the syndrome can be achieved by gradually increasing nutritional intake. There is substantial variation in opinion about the level at which to start re-feeding a patient with anorexia nervosa. Some units follow NICE (2006) guidelines for adult nutrition support, which recommend starting at 5kcal/ kg/day for a patient weighing 32kg. Although the guidance excludes eating disorders, it is considered by some to be relevant to patients with severe anorexia nervosa. However, there is wide variation in its application, some physicians and dieticians applying it strictly and others regarding it as not applicable to this patient group. One of the very few published guidelines in this area from the USA, referring to the treatment of children with anorexia nervosa (Sylvester & Forman, 2008, p. 393), advises:  Patients start on 1250–1750 calories, depending on the patient’s intake prior to hospitalization and severity of malnutrition, and advance by 250 calories daily. For patients with very low weight (<70% average body weight), the protocol is altered and caloric intake requirements may be decreased to avoid re-feeding syndrome, and advancement takes place over a longer period. (MARSIPAN)

Sometimes physicians are torn between the risk of re-feeding syndrome, and the risk of further weight loss due to not eating enough which then could mean death. In addition;

One physician in the group suggested that it was perhaps less harmful to risk re-feeding syndrome, which can be monitored and corrected, than brain damage and death caused by low glucose in a patient with hypoglycaemia. It was also commented that if higher calorie levels were thought to be essential (e.g. to correct low glucose), a critical care approach with constant monitoring and correction of abnormalities should be considered. (MARSIPAN)

When it comes to dangerously sick patients with anorexia nervosa, the risks have to be weighed up and a decision reached as to what is more dangerous for the patient who is in a life-threatening condition. On the subject of avoidance of re-feeding syndrome:

Avoidance of re-feeding syndrome can also be encouraged by restricting carbohydrate calories and increasing dietary phosphate. When patients are prescribed oral or enteral nutritional supplements, consideration should be given to the use of high-calorie supplements (e.g. 2kcal/ml) as they have lower levels of carbohydrate and may therefore be less likely to produce re-feeding syndrome. Moreover, the diet should be rich in phosphate (e.g. milk) to help avoid the syndrome. The total fluid intake can easily exceed safe levels, and the recommendation is 30–35ml/kg/24h of fluid from all sources. (MARSIPAN)

Remember that the MARSIPAN Guidelines described above are based in a hospital setting. 

As for more understanding on what refeeding syndrome is:

To understand what happens during refeeding syndrome, first review the pathophysiology of malnutrition. Normally, glucose is the body’s preferred fuel, coming from the intake of carbohydrates. As the malnourished body loses access to carbohydrates, it shifts to catabolism of fat and protein. With this shift, the body’s production of insulin drops in response to a reduced availability of glucose. This adaptive change to protein breakdown during prolonged malnutrition also leads to a gradual loss of cellular and muscle mass, often resulting in atrophy of vital organs and other internal structures, including the heart, lungs, liver, and intestines.
Serious complications may occur as respiratory and cardiac function declines due to muscular wasting and fluid and electrolyte imbalances. Metabolic rate, cardiac output, hemoglobin levels, and renal concentration capacity also decrease.
The body is now surviving by very slowly consuming itself…
When a malnourished patient is given aggressive nutritional support, such as PN, a number of events ensue. These are primarily driven by the change in insulin secretion as a result of the shift from protein metabolism to carbohydrate metabolism. The increase in glucose levels, which results from the composition of the nutritional support formula, increases insulin release by the pancreas. This in turn promotes cellular uptake of glucose along with electrolytes, primarily phosphorus, magnesium, and potassium. The result can be a life-threatening depletion of these vital electrolytes. (from here).

Also,

[RFS] is extremely rare but is more likely to occur in a young person with rapid weight loss and a BMI – from here.

As said above, refeeding syndrome is rare. People at risk are generally people are underweight, and have severely restricted for a week or more. However, if you have been eating less than 1000 calories for a week or more, are excessively exercising, or have been purging frequently, you may be at risk of re-feeding syndrome, regardless of BMI. If this is the case please see a doctor to determine the risk of RFS. Depending on your risk you may be hospitalised to be monitored there, you may be monitored by your doctor, or you may be okay to go home and just get your parents or flatmates to keep an eye on you.

You are most at risk in the first 24-72 hours, so don’t panic if you have upped your intake quickly and were not aware of RFS and have been eating a normal amount for a couple of weeks. You will be out of the danger zone by now.

Milky products are also really good for those with lowered phosphate levels, and are easier for the body to absorb.

As said above, there is also a problem with people being over-cautious and not increasing by enough or fast enough. If you are being monitored in a hospital setting, the staff there will decide what your calorie increase rate is. If you are home and have been deemed to be at very low risk, I advise increasing your calorie intake by 250 calories every 2-3 days until you reach 2000 calories. From there it is safe to jump to your 2500-3000+ calories.

As for a more in-depth look at warning signs and symptoms:

First, let’s look at some normal functions of phosphate. It’s needed to produce adenosine triphosphate (ATP), which provides energy for almost all cellular functions. Phosphate is an essential part of RNA and DNA, and it’s needed in red blood cells for 2,3-diphosphoglycerate production for easier release of oxygen to the tissues. Patients with signs and symptoms of hypophosphatemia or phosphate levels below 2 mg/dL require oral or I.V. phosphate replacement.

Refeeding-induced severe hypophosphatemia (serum concentration less than 1 mg/dL) can result in respiratory failure from a decrease in available ATP, which is needed to maintain the diaphragm’s normal contractility. In addition, hypophosphatemia can cause red and white blood cell dysfunction, muscle weakness, and seizures. Other factors that can contribute to hypophosphatemia include vitamin D deficiency and excessive intake of antacids, which block phosphate absorption.

Hypokalemia (serum levels below 3.5 mEq/L) and hypomagnesemia (serum levels below 1.8 mg/dL) are also frequently associated with refeeding syndrome. Mild decreases of potassium and magnesium may cause nausea, vomiting, constipation, diarrhea, muscle twitching, or weakness. A more severe depletion of the serum concentrations of potassium and magnesium can cause dysrhythmias, cardiac dysfunction, skeletal muscle weakness, seizures, and metabolic acidosis.

Your patient with refeeding syndrome may develop muscle weakness, tremors, paresthesias, and seizures… In addition, she may have cognitive changes, including irritability and confusion. (from here)

Please take note of this post. Although rather dry, it is very important.

Feminism and Recovery from a Restrictive Eating Disorder

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In recovery from my eating disorder, feminism has been one of my best friends, along with the body positivity movement, which I shall focus more specifically on in my next post. Feminism is a movement that believes in equality between men and women. I am aware that there are various different subsections of feminism, but to me, feminism only has one definition: equality between men and women, which includes all races, genders, and sexualities. Equality, between everyone, everywhere.

My partner between the ages of 19 and 21 was a feminist. He was passionate about politics, and although that didn’t interest me much at the time, my curiosity grew as I entered recovery. I’ve always believed in equality and so at heart have always been a feminist, but my real understanding of it and the way inequality had effected me personally dawned on me throughout recovery as I studied it more closely and became involved with it as a movement. I found that it had an impact in all areas of my life, not least in my recovery from my eating disorder.

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Feminism empowered me as a woman, and as a person. It told me I could be who I wanted to be. It told me I did not have to be limited in the activities that I do, or the things that I am interested in. It told me I could wear whatever I wanted to wear. It told me that I did not have to conform. It told me that my body could be any shape, size, or weight, and still be not only acceptable, but beautiful. It told me that I am allowed to feel proud and strong and that no one has the right to try and bring me down. It told me that I hold as much worth as everyone else around me. This applies not only to women, but to men too. Feminism also taught me a whole lot about the sexism that exists around us all of the time in our every day lives – things you may not have even noticed, like casual jokes, or comments that put down women without us even realising it (“you scream/hit/run/etc like a girl” – as if being a girl is a bad or lesser thing, or “grow a pair” – like being a man is a stronger or better thing).

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Feminism is also extremely body-positive. It tells you that you can wear what you like, regardless of your weight, shape or size. It tells you to be proud of your body. It tells you that you can shave, or not shave, and that doing either is fine. It tells you that you can have short hair or long hair, that you can wear make up or go make up free, that you can wear a bra or not. It tells you that you can choose to do whatever you want with your own body, and that you can display it how you like. It tells you that you can be short, tall, fat, thin, black, white, man, woman, redhead, brunette, flat-chested, big-breasted, and so on and so forth, and be a beautiful, proud, confident person. You can have any type of body and accept it how it is and recognise that others should also.

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Feminism taught me to embrace my body. My body is strong. It has kept me alive and has enabled me to be well again. It carries me and everything inside me. It enables me to go on countryside walks and play badminton with my friends. It is the strength to move furniture around and carry anything at all! It lets me see and touch and smell and hear and taste. It works every day to keep me as healthy as it can, and I work with it to do the same.

It also taught me that I am not just my body. I am a daughter, sister, friend, writer, reader, artist, photographer, poet, determinist, feminist, liberal, listener, warrior, traveller, baker, film buff, dreamer, and so much more. My body is fabulous, but it doesn’t define who I am. Feminism helped me to realise what is important and it helped me to realise what I am passionate about too.

Feminism planted a seed of power and confidence inside me, and it has been growing every since. It helped me to feel strong when I was feeling weak. It helped me to feel more positively about my appearance when I was struggling to look in the mirror. It helped me to appreciate my body when I was berating it. It helped me to fight when I wanted to give up. It helped me to develop pride in myself as a person when I was feeling worthless.

Feminism was invaluable to my recovery. I’m so thankful that I became aware of the movement when I did. Maybe it can help you too.

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What Does Being Fully Recovered From An Eating Disorder Look Like?

freedom

It’s a big question, but often people in recovery ask it: what will it mean to be fully recovered?

Before you read my own experiences of being in remission from a restrictive eating disorder, you might want to read my post: Am I Still Disordered? which can help give you some idea as to if you still have things to work on in your recovery.

Being fully recovered will mean different things to different people, but this post is about what it means to me and how I think it should be for people when they are in remission from their eating disorders.

For me, remission means that I eat what I want, when I want, and I don’t worry about that making me gain weight – and it doesn’t. I maintain my weight by following my hunger cues and cravings. I trust my body and I eat what I want to eat. I never make excuses not to eat something that I want to eat, and I don’t ever choose food based on calories or macros.

For me, remission means that I accept my body as it is. I don’t love it, but I don’t loathe it any more or have the intense desire to change it. I have accepted it as it is, and always try to see it in a positive light. Some days I am unable to feel positively about my body, but I accept that I will have bad days and then put my mind and thoughts to better use.

For me, remission means that I can enjoy being active, but I know it won’t have any effect on my weight or shape, and my reasons for doing it are not linked to my body. I do not engage in exercise that I do not enjoy because that would be disordered. I engage with physical activity that I find genuinely enjoyable and any health benefits come secondary to me having fun. For me, exercise has got to be something I look forward to doing, enjoy participating in, and feel good about after. At no point must I feel like I am forcing myself to do it. This means that for me I tend to do physical activity when other people are involved. I don’t see exercise as exercise – I see the activities I do that are physical as just another of my hobbies.

For me, remission means that I do not resort to eating disorder habits when angry, stressed, or upset. It means treating myself, relaxing, talking to other people, and doing things that I enjoy to make myself feel better.

For me, remission means that I don’t second guess myself when it comes to food. I don’t think about becoming “healthier”. Food isn’t so important to me any more – except for the fact that I now really enjoy it instead of feeling anxious and guilty! I am now myself and not my eating disorder. I am a woman who is interested in feminism, psychology, writing, reading, social politics, blogging, watching movies ad TV series, seeing friends, art, baking, swimming, badminton, and helping others in their journey towards recovery. I have energy and I put that energy towards my passions. I am now focussed on the things I enjoy and the things that are important to me, and my eating disorder does not play a part in my life any more.

For me, remission means that I am now able to do whatever I want to do, without being limited by anxiety towards food. I eat lunch at the pub with my friends, and go for evening drinks with them. I can go out to restaurants and end up eating a bit too much (as in, can’t stand up for half an hour because you are so full because you just had to have a dessert because it looked too good not to get it) and not think anything of it. I can go out for coffee and cake and sandwiches and picnics and eat whatever my mum has cooked for dinner without worrying about what is in it. I can lie in bed all day and not feel lazy. I can go for a stroll and not worry that I’m walking too slowly, because my reason for walking is not burning calories any more – it’s because I am enjoying the countryside or getting from A to B, or taking a walk with my brother.

My body is now not particularly important to me, in so far as it doesn’t take up much of my head space. I am eternally grateful to my body for keeping me alive, and for healing me when I decided to work with it rather than against it. I am thankful that I am strong, and healthy, and I am thankful that I am able to be me again – the real me that I am supposed to be, rather than someone taken over by an eating disorder. I do not body check, and I am not distracted by how my body looks. I live life, and rarely think about how my body looks like doing it.

There are always traps that you can fall into when you are in remission. Remission does not mean that your eating disorder is gone entirely. Occasionally, you may come across something that triggers the little ED voice to pipe up. In remission, I have found that I don’t have that many triggers any more, but there are some that still remain. When the ED voice pipes up, I tell it in a very bored manner to shut up and go away, and I never act on it. When it gets ignored, it slinks back into hiding in a dusty corner somewhere in my mind. Usually, I do the exact opposite of what it is telling me to do, just to show it how much it is not going to affect me. It generally does a vanishing act then.

In remission, my eating disorder has no impact on what I do in my life, and how I do it. I am now a functioning, healthy, energy-balanced woman, living out her life in relative peace from the eating disorder’s voice. It has no place in the life that I have made for myself by fighting the eating disorder and winning. I now do things freely. I enjoy my hobbies, I work hard at my passions, and I have a full time job doing something that is extremely important to me. I have healthy relationships, eat well, and take care of myself. The life that I now have is full of me being me, and that’s what remission is all about.

Am I Still Disordered?

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So you have been recovering for a fairly long time and have come a very long way. Your life has improved dramatically, you feel like you are eating well (what you want, when you want), and you’ve let your body rest up and repair, and haven’t engaged in formal exercise for a significant amount of time. You feel healthy, you feel pretty happy, and you’re wondering to yourself: how will I know when I am fully recovered? How do I know if my eating habits and thought patterns are still disordered?

This is definitely something that I thought about when I was recovering, and I am pretty sure it is something that you have thought about too. When exactly do you know when you are in remission as opposed to still recovering? When is that point where you go from one to the other? What signifies it?

The things that are disordered vary from person to person. One person may never has used coffee as an appetite suppressant or for energy during their eating disorder, and may now just enjoy a cup or two a day, whereas another may have used it and are still using it under the pretence of enjoying a cup or two a day, but are in fact not being honest with themselves that it is in fact driven by their eating disorder. One person may avoid some foods because they genuinely don’t like them, whilst others may avoid the same foods because their eating disorder has persuaded them that they don’t like them. It all varies from person to person, and it is about being 110% honest with yourself as to whether you are going to keep progressing forwards and reach remission or not. Because of these individual differences, it is hard to put together a whole list, but here are a few things that are signs that your eating habits and thought patterns are still disordered.

1. You are still worrying that food is going to make you fat, and you still worry about when to stop eating. This is something that when you are fully recovered you will not think about. You will eat what you want, when you want. You will eat when you desire to eat, and when you don’t have any desire to eat, you won’t. You will not worry about it “making you fat” because you know your body will maintain its natural healthy weight whilst you eat what you want, when you want.

2. You are finding reasons to not eat something. You should always eat what you want, when you want. If you are trying to find reasons not to eat something, then you are still having disordered thoughts. You eat when you want to eat, and you don’t eat when you don’t want to eat. By not wanting to eat, I mean that food is unappealing because you are not in any way hungry or needing any energy.

3. You are linking food and exercise together. Food and exercise should come separately. Burning off calories from your meals = disordered. Only allowing yourself to eat what you want because you have exercised = disordered. One should not effect the other.

4. You are still trying to control your weight. Being in remission includes accepting your body at whatever weight it is healthiest at naturally. That means trusting it to take you to that weight without you restricting any types of foods, exercising to try and keep your weight from going up, or trying to keep to a certain amount of calories without going over. It means eating what you want, when you want, and not exercising (or later on, only exercising for fun), and allowing your body to do what it needs to do.

5. You are trying to convince yourself that you enjoy exercise that you don’t really enjoy doing. Exercise should not be a part of your recovery. It should only be done in remission. If you are trying to convincing yourself that you love going to the gym when you don’t, start being honest with yourself. If your eating disorder has persuaded you that you love aerobics when actually you don’t, be honest with yourself. This includes “I’m doing it to be fit/toned/healthy”. That’s still disordered. Exercise should not be linked in your mind to changing your weight, shape, or size. Exercise that you don’t genuinely enjoy should not be done to get fit or healthy. It is the enjoyment that should come first and foremost, and the health benefits are secondary benefits that should have had nothing to do with the decision to do something physical. “I feel great after though!” is not a valid excuse. If you are going to do any form of recreational physical activity, you should feel good before doing it, whilst doing it, and after doing it, not just the latter. I would suggest checking out my videos on exercise here, here, and here).

6. You are avoiding certain foods or food groups. You might convince yourself that this is for “health” reasons, or you may even convince yourself that you don’t like them when actually you do. Again, this is about being really honest with yourself. Are you just trying to avoid them because they make you anxious?

7. You hate your body. Those in remission are able to accept their body as it is naturally. This doesn’t have to mean loving it. It just means being at least okay with it.

8. You lapse when you are stressed, angry, or upset. Those who are fully recovered have healthy coping mechanisms and do not respond to stressors by engaging in eating disorder habits.

9. You are still weighing yourself frequently. You do not need to weigh yourself any more. You don’t need to weigh yourself at all, ever. The number on the scales is irrelevant and for those with eating disorders, is a massive trigger. Those in full recovery don’t bother stepping on the scales because it’s meaningless and they don’t need to know their weight.

10. You keep planning ways to be “more healthy”. Those in remission eat what they want, when they want, and don’t need to think about “being healthy”, because what they are doing is what is truly healthy – listening to their body and not trying to control food or their weight, and eat what they desire, when they have the desire to do so.

Those are the ten things that sprang to mind when I thought about things that aren’t always entirely obvious to the person engaging in those habits or thought patterns. I hope this makes you think about where you are in recovery and if you still have some things to work on. Remember that these things take time, and you don’t have to rush to the finish line. If you try to do that, that finish line will get further away. Be patient and gentle with yourself, always.

Anxiety Management

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Anxiety can feel extremely overwhelming when in recovery for an eating disorder. As I talked about in the FAQ, it is pretty much impossible to avoid anxiety when it comes to the recovery process, and that is one of the reasons as to why recovery is so difficult.

Again, as I have said in the FAQ, I use this metaphor for eating disorders and recovery: There is a terrifying dragon in your garden, and every time you try to leave your house the dragon tries to eat you. You have a choice: you can resign yourself to being trapped in your house forever, or you can find a weapon and go out and fight it.
These are the choices you have regarding your eating disorder. You can either choose to remain trapped by it or you can face yours fears and fight it. You can only make the anxiety calm down and eventually stop altogether by facing your fears regarding food, weight, and other eating disorder habits. You can only make it stop by going against your eating disorder. For example, check out this path below:

path

This path has been created by people walking along it. Someone walked that way then another person did then another, and they all kept walking over this one track more and more, making the path deeper and more worn in until it was a very clear path that everyone would now automatically follow rather than walking along the grass beside it. This is what happens in your brain: the more you do something the more it becomes the norm to follow. So if you respond to your eating disorder over and over again, that becomes the habit to follow and not doing it creates anxiety. When you fight against your eating disorder, you start treading on the grass that isn’t the path. At first this is anxiety-provoking and scary, because it is not the norm, and it will continue to be scary for a while, but each time you are making more of a path in a different route. Eventually, that route will become a solid pathway, and the other one will start to disappear as grass starts to grow on it again. Eventually the old route will disappear and the new one will become the norm. What I am saying is that to do new things creates new neural pathways in the brain, making your new behaviours eventually become normalised (right now your old behaviours – those created by your eating disorder – are normalised because you have repeated them so often). This is when the anxiety will start to lessen. The more you do something the easier it will become, and eventually it will become easy, and the norm.

So anxiety is going to be something that you experience during your recovery. Maybe that anxiety occurs before you challenge yourself, maybe it occurs during, or maybe it occurs after, but either way, it’s there, and you don’t know what to do about it. You probably feel like responding to your eating disorder, which is probably telling you either not to challenge yourself, or to compensate for doing so. Ignore that voice. I know it is extremely hard but that voice is trying to make you sick. It is trying to get you to live in misery. Ultimately, it is trying to kill you. So how do you cope with that extreme anxiety when it is upon you?

anxiety

One thing that is important is distinguishing its voice from yours. Recognise what is you, and what is the eating disorder. Argue with it. Use your rationality. Use your logic. Use the facts against the negative feelings it is trying to evoke in you. Beat it with logic.

One of the best ways to deal with anxiety is to use distraction techniques. When you are feeling anxious, distract yourself by doing what you can get most absorbed in. Here is a list of suggestions:

  • Watch a movie
  • Read a book
  • Write
  • Paint or draw
  • Blog
  • Collage
  • Knit or sew
  • Research something you are interested in
  • Play XBOX
  • Play games on your phone
  • Do fun internet quizzes
  • Play computer games
  • Call a friend or family member
  • Meet up with someone
  • Watch a documentary
  • Play a musical instrument
  • Do homework
  • Tidy your room
  • Do some internet shopping
  • Take photographs
  • Do puzzles

Puzzles in particular are very good for distraction as they really engage your mind and so distract you from the negative emotions you are experiencing.

Other things that you can do include:

  • Doing things which evoke a different emotion in you from the one you are experiencing. This could mean reading emotional books or letters, or looking at photos that bring up happy memories. It could mean watching films that evoke a different emotion to anxiety, such as a comedy, romance, or even a horror! It’s also good to listen to happy music when feeling sad, or calm music when feeling anxious. We tend to listen to angry music when we are angry, or sad music when we are sad, but this only reinforced the emotion rather than helping it to settle down.
  • If you are really, really anxious, and feel like you can’t contain yourself and are reaching a very intense level of anxiety, you can use the ice diving technique. If you are on beta blockers, have a heart condition, or any other medical condition, consult a healthcare provider before doing this. The ice diving technique means filling a bowl with ice, and sticking your face in it. This lowers blood pressure, heart rate, and body temperature, which helps with distressing emotions and reactions and lowers the anxiety levels. It can take around 15-30 seconds for the effects to occur.
  • Changing your environment can be good when you are anxious. Whether that means going to an imaginary safe place in your head, going to a place in your house where you feel most safe, going for a brief calm walk, or going to a friends house, a change in scenery can help calm you down.
  • Keep your reasons to recover in mind and find purpose in those negative emotions. For example: “I’m doing this because I want to recover.” Knowing that these negative emotions are playing a part in moving forwards can help.
  • Relax your body. Tensing up, which is a natural reaction to anxiety and stress, signals to your body that you are in danger and therefore continues to make you feel anxious. Try to relax. Let your shoulders drop. Lean back into a sofa or lie down on the bed. Unclench your muscles. This signals to your body that you are not in danger, and so can decrease anxiety.

Anxiety relating to recovery from an eating disorder is unpleasant at best, and overwhelmingly awful at worst, but it is something that can be managed, and something that will improve when it as your recovery progresses. If you can, do get a therapist to help you to help yourself throughout this difficult time. Hang in there, you can do this!

Treatment and Support Options for Eating Disorder Recovery

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Recovery will be the best choice you have ever made for yourself. You will be choosing life over death. You will be choosing health over sickness. You will be choosing happiness over misery. However, recovery can be daunting. It can be terrifying and extremely difficult and immensely challenging. It can bring with it feelings of anger, guilt, sadness, shame, anxiety, and pain. It can leave open wounds that you were trying to cover by using your eating disorder as a band aid. It can uncover truths and experiences and memories you were trying to suppress. Because of this, it is important that you use all opportunities given to you in the form of professional support. This can be harder in countries where you have to pay for all professional help and do not have the NHS, but it is still possible to find help and support even if you are strapped for cash.

In this post I am going to go over some of the treatment and support options that you might want to consider.

Inpatient/hospital 
Inpatient treatment would be provided in a hospital setting. The main aim of inpatient is to medically stabilise the patient and get them back to a healthier weight, before discharging them. In most cases they would be discharged to a residential setting for continued care.

Residential
People using these services reside at a live-in facility where they are provided with care at all times. This means that they are under constant medical supervision and monitoring of both physical and mental health. Treatment programs within residential facilities are usually very structured, and they provide an environment in which the client can focus solely on physical and psychological healing with a great deal of support from their treatment team.

Intensive Outpatient (IOP)
Intensive outpatient is suited to those who need more professional support than outpatient treatment but still need flexibility to continue their education or job. IOP Programs generally run at suitable times for the participant, ranging from 2-5 days a week. Treatment usually includes therapy, nutrition consultation, topic focused groups, and/or family support groups.

Outpatient
Outpatient is much less restrictive than inpatient, and is good for those who have a job or are attending school or any other form of education. It is also an option for those who do not have the insurance to cover higher levels of care, but still really need a moderate level of support to aid their recovery. Those in outpatient programs may see a therapist, nutritionist, and other recovery professionals around 2-3 times per week.

Therapy
For those who don’t want to consider inpatient, outpatient, or residential, or who cannot get a placement for any reason (and that will be the majority of those with eating disorders), there are many options where therapy are concerned: Cognitive Behavioral Therapy (CBT), Medical Nutrition Therapy, Dialectical Behavioral Therapy (DBT), Acceptance and Commitment Therapy (ACT),  Art Therapy, Dance Movement Therapy, Equine Therapy, Exposure and Response Prevention Therapy (ERP), Family Therapy, Interpersonal Psychotherapy (IPT), Cognitive Analytic Therapy (CAT), The Maudsley Method (also knows as Family-Based Treatment), and Mindfulness-Based Cognitive Therapy (you can find out more about these therapy methods here, here, here, and here).

For those who cannot afford therapy and are in education, see if your school, college, or university has counsellors on site that may be able to provide you with free support. You may also be able to find therapists at reduced costs who have been fully trained but have not clocked up sufficient hours yet.

Support Groups
If you cannot afford any therapy, cannot get any using the NHS, and are not in education or have none in your educational institution, check out if there are any support groups near you that you can utilise.

If you cannot find a therapist or support group, you could ask the NEDA Navigator service to help you find support in your area – wherever you are from – or just to vent to and get some support from. (Beat also have a HelpFinder).

Doctors
If you can, do make sure you are seeing your doctor regularly, or at least semi-regularly, to get updates on your health. Again, I know this can be a money issue for a lot of you, but it is really important that you know where you are where your health is concerned. Doctors can also help you find support groups, and give you referrals for therapy, inpatient, or outpatient programs.

Helplines
If you are struggling to find any support, do know that there are many helplines available. There is NEDA’s information and referral helpline (there is also a Click to Chat option so you can instant message if you would prefer to do it that way), there is BEAT’s 1-2-1 Chat Online service, BEAT’s online services, and BEAT’s helplines.

Forums
I would advise being careful with forums, as they can often lead to triggering discussions, but if you are going to visit forums (and they can provide invaluable help and support) I would advise BEAT’s forums, NEDA’s forums, or the forums on Your Eatopia (the latter has a tiny fee but I would say it is really worth it – personally it helped me more than anything during my time in recovery).

Self Help
There are self help options such as books on certain therapies (like CBT workbooks), anorexia and bulimia workbooks, other eating disorder workbooks, online resources etc that can help you work through your issues with the help of workbook exercises, challenges, and reflection.

I hope that if you struggling and don’t know which way to turn, this comprehensive list enables you to find help and support during your recovering from your eating disorder.

If I have missed any that are important, do let me know!

Shouldn’t I Be Recovered By Now?!

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In recovery, it is easy to become impatient with oneself about the time it is taking. We can often find ourselves wondering if it is not time that we are fully recovered already. Human beings seem to be particularly easy to agitate when quick results are not apparent.

However, recovery takes time. And by time, I mean it could take years. It could mean moving forwards bit by bit over a long period of time, overcoming obstacles at a slow but steady rate. It could mean overcoming many obstacles within the first six months but then finding that certain habits and thought patterns are lingering, and taking the next couple of years working on those leftover aspects of your eating disorder. It could mean mentally recovering within a year but physically recovering within three. It could mean physically recovering within a year but mentally recovering within five.

You have to be patient: patient with your body, and patient with your mind. You have to put all of your determination, dedication and perseverance into your recovery and realise that it is going to be exhausting and time-consuming for quite a long time, but the outcome is going to be worth it.

You may think that you are recovering too slowly and that you should be done with it by now, but you have to let the body and mind heal at its own pace. You can’t force yourself into remission. There is so much to work on, and undo, and repair from. Recovery is a delicate process, and it is a journey. Like with all journeys, it’s not just the destination that is important: it’s also what you learn and discover along the way that makes for a robust and stable remission.

After 18 months in recovery, I was pretty stable, but I still had lingering eating disorder thoughts and habits: counting calories, weighing food, a fear of white carbohydrates, unhealthy exercise habits, and an intense dislike of my body. It felt like these things were never going to go away because they were habits that were persisting even though I kept trying over and over again to challenge and overcome them. I felt like I was bashing my head against a brick wall. Then I tried knocking down the brick wall. I tried climbing over it. I tried driving a vehicle into it. I tried to find a way around it. Nothing seemed to be working, and I was giving up with it. I felt like my recovery had come to a dead end, and that I was going to progress no further.

Sometimes in that time period I felt like going back, because I wasn’t going forwards, and I wanted to be moving somewhere. However, I kept at it, and continued developing and growing in front of that brick wall. Then one day, I realised the wall wasn’t there any more. It sounds too good to be true, but that’s honestly what happened. I had been avoiding white pasta and rice, and continuously choosing wholemeal or wholegrain bread over white bread for a really long time, and had also been spending countless occasions forcing myself to eat white carbs when I suddenly realised that I was now eating them without any anxiety whatsoever. I can’t pinpoint when it changed for me. I just one day recognised that I had been eating white carbs without anxiety for a while, and wasn’t trying to avoid them any more.

The same thing happened with the other habits. One by one, they stopped becoming an issue. What once seemed like an impossible task became something that I had faced and overcome. I stopped weighing my food, I learned to use exercise in a healthy way, I accepted my body as it is naturally, and I stopped counting calories. I had tried so hard to force the wall down, but in the end, it came down in its own time, and the effort was in staying facing that wall rather than turning my back on it and walking back the way I had come.

Be gentle and kind and patient with yourself. You are recovering from something that is very complex, and very severe, and it is going to take time. Don’t pressure yourself or set a time limit as to when you think you should be recovered. Allow yourself all the time in the world. That time will help you.