Tag Archives: mental illness

New Year’s Resolutions vs Eating Disorder Recovery

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So New Year’s Eve has come and gone, and people are scribbling their new year’s resolutions all over social media and bringing them up in conversation. And if truth be told, it’s boring. It’s boring and it’s pointless, because most people jump simultaneously on the resolutions and diet culture band wagon and publicise their diet/weightloss/health/exercise #goals for 2016, which predictably (and thankfully) are forgotten about a month or so into the year.

For some people, it’s not just boring, it’s anxiety-provoking, and those people are those recovering from a restrictive eating disorder. After knuckling down and recognising and accepting that weight gain is part of the process, as is eating much more, ceasing exercise during recovery and cutting it down in general for life, and eating and regaining a healthy relationship with “fear foods” which generally consist of high fat, high carb, or high sugar foods/food groups, they then have to watch everyone pledge to lose weight, exercise more, and cut down on “unhealthy” foods.

If you are one of those people, it’s going to be hard seeing and hearing about all these new years resolutions that trigger negative thoughts and emotions, and tempt you to engage in the same behaviours that for most would end in the cessation of them, but for you would end in the spiral back down to misery and sickness, and could end in death. It could be an obvious impulse to just say “fuck it” and relapse, or it could come under the manipulative guise of “health” – that eating disorder voice whispering in your ear that going paleo, cutting down on carbs, or hitting the gym would not be a behaviour but just a way to get healthier (Nope. It’s a behaviour. It would be many steps backwards and the path to full relapse). If you are experiencing any of the above difficulties, you need to remember to focus on yourself. Other people’s behaviours should not impact on your own. You know where it would lead you, and it is important to make it your utmost priority to do what is best for you, your recovery, your happiness, and your health. Don’t allow other people’s insecurities and anxieties about their weight and shape influence your own actions. Instead, empathise with them. Know that they are not feeling happy with themselves and hope for their sake that they find a way to accept their bodies as they are naturally and celebrate themselves as beautiful people with beautiful bodies.

Remove toxic relationships or negative people from your life if you are finding a certain person consistently triggering. Unfollow people on social media who are likely to post/continue posting about weightloss, dieting, exercising, or anything else that triggers you as an individual. Talk to the people in your life who try to have conversation with you about their diet or exercise routines or similar, and let them know that it is unhelpful for you. Those who love you and care about you will cease pushing these topics on you. Those that don’t are the toxic, negative people in your life that I mentioned above.

Finally, know that your recovery is mandatory. You need to do what is best for you and your recovery, and that means fighting the negative thoughts and getting rid of any constantly triggering people. You deserve to live a happy and healthy life. Keep working for that, and keep moving forwards. You can do this.

Exercise (pt 2): Exercise and Eating Disorders

exercise addiction

This is the second part to the article I wrote last time, which talked about exercise in general and the way that an unhealthy mindset around exercise has infiltrated our society as a whole.

Today I want to talk about exercise and eating disorders.

Like I spoke about two weeks ago, nearly everyone views exercise as something that is healthy, regardless of how it is used. During my recovery from my eating disorder, I told a friend about my compulsive exercise and about how I was trying to challenge it because I was doing x amount of exercise a week because I felt that I had to, and hadn’t been able to stop myself from doing it even when I didn’t want to. She genuinely replied with “Yeah but that’s fine because exercise is good!” Because we have such a warped view about exercise, many people don’t seem to understand how detrimental it is to those with eating disorders, especially when it doesn’t appear to be severe.

Some people with eating disorders push themselves to the extreme when it comes to exercise. Some people exercise for five hours a day, and some more. Some people never let themselves sit down – ever – except when sleeping (and I’ve even known someone to sleep standing up). It is easier for people without eating disorders to understand why this might be a problem, but when you are someone with an eating disorder who exercises in a way that people might perceive as inspiring and healthy; in a way that people might see as #goals; in a way that people aspire to, you may end up with congratulations rather than concern.

For those who have exercise addiction, you can’t just stop when you want to, or give yourself a day off (unless you already have a “scheduled” day/time, and then it must be that day/time and none other). You will miss social events if it coincides with your sessions. You will feel incredibly anxious before exercising, and after the exhilaration of finishing a workout has subsided, you will feel the dread of knowing that in less than 24 hours you will be repeating the same monotonous and exhausting work out. You will continue with your exercise routine however much you don’t want to do it, however tired you feel, or however sick you are. It is not enjoyment that drives someone with exercise addiction: it is the perceived need to do so.

As well as being mentally draining, compulsive exercise (also known an obligatory exercise or in extreme cases, anorexia athletica) can have a negative effect on the body. Firstly, by working out intensely every day, the body is being put under a lot of strain, and is not being given any time to recover, which is needed. Those addicted to exercise will work out even if they are ill or injured, which could have serious consequences to their health, including damage to tendons, ligaments, bones, cartilage, and joints. When injuries happen and are not given enough rest to heal, this can result in long-term damage. If the body is not getting the nutrition that it needs, muscle can be broken down for energy instead of building muscle. Girls and women could disrupt the balance of hormones in their bodies, which can change menstrual cycles and even lead to the absence of them altogether. It can also increase the risk of premature bone loss, which is known as osteoporosis. The most serious risk is the stress that excessively exercising can place on the heart, particularly when someone is also restricting their intake, or using self-induced vomiting to control their weight. Using diet pills or supplements can also increase the risk for heart complications. In worst case scenarios, restrictive eating disorders and compulsive exercise can result in death.

The reasons behind exercise addiction can be complicated when it comes to eating disorders. For many people it is an additional means of furthering and/or quickening weight loss, or it could be the main part of someone’s eating disorder, in order to get “fit” or muscular (anorexia athletica). It could be about control. It could be, like the rest of the eating disorder, a form of distraction from feeling or thinking certain things. It could be part of orthorexia (an obsession with eating “healthy” or “pure” foods and leading “healthy” or “pure” lifestyle). Athletes, dancers, wrestlers, gymnasts, and other people who are fixated with keeping in shape and keeping their weight down for their careers are also susceptible to developing exercise addiction.

Although it is not listed in the Diagnostic and Statistical Manual of Mental Disorders, exercise addiction is a serious and potentially life-threatening obsession, and needs to be taken extremely seriously. It is not just a strain on the body but a strain on the mind. It is absolutely exhausting, and completely miserable to experience. It can take up a huge amount of your life and a huge amount of your thoughts, and is extremely unhealthy for your physical and mental health. Whether it  is the main part of an eating disorder, a lesser part of an eating disorder, or a disorder on its own, compulsive exercise is serious. It is something that must be challenged and overcome as part of recovery from an eating disorder, and must be ceased until the unhealthy relationship with exercise is broken and remade into something healthy. Only in remission can someone make an informed and healthy decision about whether to restart exercise and how much/what to do in regards to moving their body. Even then, it’s a fine line.

I talk more about a healthy relationship with exercise in part 1.

If you think you may be developing/have developed an addiction to exercise, seek medical help from your GP.

Signs that you or someone you know may be suffering from compulsive exercise include (but are not limited to) the following:

  • Not enjoying exercise sessions, but feeling obligated to do them
  • Seeming (or being) anxious or guilty when missing even one workout
  • Not missing a single workout and possibly exercising twice as long if one is missed
  • Seeming (or being) constantly preoccupied with his or her (or your) weight and exercise routine
  • Not being able to sit still or relax because of worry that not enough calories are being burnt
  • A significant amount of weightloss
  • Increase in exercise after eating more
  • Not skipping a workout, even if tired, sick, or injured
  • Skipping seeing friends, or giving up activities/hobbies to make more time for exercise
  • Basing self-worth on the number of workouts completed and the effort put into training
  • Never being satisfied with his or her (or your) own physical achievements
  • Working out alone, isolated from others, or so that other people are not aware of how much exercise is being done
  • Following the same rigid exercise pattern.
  • Exercising for more than two hours daily, repeatedly

(sites used for reference and more information: 

http://www.brainphysics.com/exercise-addiction.php
http://addictions.about.com/od/lesserknownaddictions/a/exerciseadd.htm
http://kidshealth.org/parent/emotions/behavior/compulsive_exercise.html
http://en.wikipedia.org/wiki/Exercise_addiction )

Exercise (pt 1): Is it Part of Your Healthy Lifestyle, or Are You Waging War on Your Body?

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My first ever blog post was on the dangers of exercise addiction, but I wanted to reboot this topic and do it over in two parts, focusing more on exercise in recovery from an eating disorder (in part 2), as well as exercise in the general community (part 1 right here), and the effects it can have on both sets of people.

Exercise is something that those with eating disorders use and abuse to lose weight, change their bodies, and deal with negative thoughts and feelings in a negative and unhealthy way, but it is also something that has become a toxic part of many people’s lives in the community at large. It has become something that is unhealthy for many people who are engaging in it.

“Exercise…unhealthy?!” you gasp in disbelief, “How can something that is clearly part of a healthy lifestyle be a problem?”

The issue with exercise in our society now is the way people exercise. The issue is why people exercise. The issues are the mentality: the thoughts and feelings behind what is driving someone to exercise, and the outcome that they are looking for.

If you look around at the media, at health food blogs, at doctors recommendations, at magazines, books, and website articles, then you will see that women primarily, but also men too, are constantly being told that they should be exercising in order to lose weight or become toned, or in some way alter the way that their bodies look. I frequently see my friends updating their Facebook statuses letting us all know they have had an intense session at the gym, or tweeting about how they don’t want to go out for a run because it’s cold but that they need to. I see “healthy” lifestyles which include clean eating (eliminating all processed foods and extra additives from your diet, and only eating whole, unrefined foods) and regular exercise all over blogging sites. I can’t seem to avoid fitspo. Society has become obsessed with it.

There are people who genuinely enjoy the physical activities that they pursue as hobbies. There are people who don’t like the physical activities that they choose to do but feel that the results are worth it.  There are people who cannot stand to do the physical activity that they force themselves to do but feel like they have to do it because of whatever the driving force behind their exercise is – which is usually body hatred.

In my opinion, only the first of the three types of active people that I mentioned should be exercising. The others should cease exercise and heal their relationships with their bodies and themselves before resuming any physical activity. They should find physical activities that they genuinely enjoy that are primarily focused on having fun and/or socialising rather than changing the way their bodies look.

Don’t get me wrong, I am not condoning a lifestyle of sitting on the couch eating Chinese takeaways and playing videogames forever after (but if that’s what makes you happy, by all means, go for it! No judgements made), as I believe movement is part of a healthy lifestyle, but I do not think that anyone should be forcing themselves to do a workout that they don’t find any enjoyment in. I do not think that anyone should be wasting time engaging in activities that they do want to do purely because they are driven by a society telling them that their bodies are not good enough as they are and/or that they are lazy and unhealthy if they do not engage in x amount of physical activity doing certain types of exercise.

“I really don’t want to go the gym today, but I know I need to/have to/should,” is a common comment that I hear from colleagues, friends, and strangers, and this is a result of the insidious and toxic system that is diet culture. Nobody has an obligation to engage in physical activities that they don’t enjoy. Nobody should.  These days we see exercise as something we don’t want to do, but something that we have to do. Doctor’s orders. Exercise has become something we associate with gyms and aerobics and gruelling runs, which most people don’t really enjoy. We’ve lost touch of recreational activity: doing things that we enjoy that involves physical activity. The enjoyment part is primary, and the activity secondary.

Being active is great, but only when you have found something that you actually enjoy. This could just be leisurely strolls through the countryside, or hikes in the hills. This could be swimming with your kids, or challenging a friend to a few badminton games. This could be finding a team sport that makes your heart race and your grin wide. It could be practising mindfulness through yoga, or getting competitive with a colleague whilst playing squash. This could be once a week or once a day. Whatever makes you happy. Not whatever makes you lose weight, or whatever gives you abs. Not whatever gives you a tiny waist or bulging arm muscles. Not whatever burns the most calories. Whatever makes you happy.

Physical activity should be done only if it adding to your life, not something that comes at a cost. Not something that you dread. Not something that you have to make yourself do. Exercise is something that is pushed on us as categorically healthy, but it’s just not when it comes at the expense of someone’s mental or physical health, and it’s not when the drive behind it is body dissatisfaction, or downright body hatred. On the extreme end of the spectrum, exercise can also turn into a dangerous addiction, and in the case where exercise becomes the focus of someone’s life it needs to be taken very seriously, and this is something that I will talk about in my next article in the coming weeks (part 2).

If you are exercising not because you want to, but because you feel that you should, or have to, then I would highly suggest that you take time out, stop the exercise that you have been engaging in, and take the time to evaluate if what you are doing is actually benefiting you. Assess your reasons for exercising, and start building a positive and healthy relationship between you and your body. Because you need it, and you deserve it. Your body is perfect just as it is. Learn to love it, not to wage war on it. Then find movement in your life that makes you smile. Find movement in your life that you look forward to. Find movement that brings you positivity, and never expend energy in the name of diet culture ever again. You are beautiful, and this is what you deserve.

 

Oh Yes, Eating Disorders Are SO Glamorous

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(TRIGGER WARNING – Eating disorder behaviours written about)

You’ve probably seen it: the glorified photographs of underweight celebrities and models; the tiny, fragile, delicate girls in movies with eating disorders (think Cassie from Skins), maybe you’ve read the overly simplified and massively invalidating Winter Girls. Anorexia is the “diet” everyone wants to be on. Well, maybe not everyone, but I’ve heard the offhand comments: “I wish I had just a touch of anorexia”or “I’d do anything to have a bit of anorexia for a couple of weeks!” Even bulimia, the less glamorised eating disorder gets a look in: “I tried bulimia but I just hate throwing up!”

Why yes, of course, you’re totally right! Eating disorders are SO glamorous.

When my eating disorder forced me to walk forty-five minutes home with a week’s worth of food shopping every week, I totally felt glamorous. When I had to pause every ten minutes because I felt like I was going to pass out, and when I damaged the nerves in my fingers from the tightness of the shopping bag handles, I totally felt glamorous. When I wet myself a little bit now and again because my body was eating away at my bladder to try and get energy, I felt more glamorous than anyone. When I vomited into the toilet and got splashback on my face, it was so glamorous: even more so when I popped the blood vessels around my eyes. When I drunkenly locked myself in my boyfriend’s bathroom and cut my all over my arms, legs, and stomach, it was as glamorous as anyone would want to be. It was also super glamorous when my eating disorder punished me by making me work out vigorously for two hours straight on a malnourished, weak, failing body, until I was at the point of collapse, and when I made myself throw up at a party and a friend heard the whole thing, and when I cried on the train because the man on the other side of the aisle was eating a sandwich and I so desperately wanted to feel “allowed” to have that; have anything. And when I had to run home from a restaurant after eating something with fats in because I immediately got diarrhoea. And also when I screamed at my partner for putting a dash of milk in our scrambled eggs, and smashing a glass and kicking him out of the house when he turned over my “notices” to myself reading “fat bitch” and “starve yourself” and wrote “you are beautiful” and “you are perfect” on the back of them instead. And even more so when all I genuinely, truly wanted was to be chained to a bed so that I could not access the kitchen and eat anything. When I couldn’t think straight and my relationship was ruined and my body was cannibalising itself and my personality had diminished to nothing so that I had no hobbies or interests bar losing weight – what could anyone wish for than a touch of what I had; a touch of what millions of people suffer with every day? Anorexia, bulimia, OSFED, ARFID, anorexia athletica, orthorexia…what more could anyone want but those restrictive eating disorders that destroy your life, take away your health, eliminate your personality, interfere with your ability to work, and wreck your relationships?

And just so you know, eating disorders don’t necessarily make you skinny. They make you sick, and they make you so miserable that you wish you would just die, and they make you more and more dead every minute, but sometimes you don’t even get to be skinny. And even when you are skinny, you’ll never know it. The skinnier you get the fatter you’ll feel. With every pound you lose, you’ll hate it with more and more passion that you’ve ever felt towards anything else, and that will only drive you to continue to lose more, in the hopes that it will make you feel better. But it never will.

So sure, go about wishing you had just a “touch” of what we have. You know that saying ‘be careful what you wish for’? It could not be more true than when it comes to this.

In addition to the idiotic notion that having an eating disorder would be worth it because you’d get skinny, having these incredibly ignorant opinions invalidates and undermines the severity of an eating disorder, thus eradicating the experiences of those suffering from them. Having those sorts of opinions makes our pain invisible, because you don’t understand that it exists.

So learn more about eating disorders, because you know someone with one. You might not think you do, but you do, trust me. Someone in your life is struggling. Don’t let their experiences be invisible to you.

End rant.

Counting Calories and Recovery

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It seems like something that would be counter-productive to suggest, but counting calories is a really important part of recovery – especially during the initial stages. Counting calories is very likely a large part of you or your child’s (or partner’s/sibling’s/friend’s et) eating disorder, so it can seem like madness to say ‘continue doing this’, but hear me out.

Whilst counting calories was used as a way to restrict, it now needs to be used as a way to heal. So we are turning around a negative habit and using it to make sure that the person recovering gets enough energy into their body. Getting enough energy is essential for recovery, and it is likely to be something that proves impossible to do unless someone is counting the calories of the person recovering.

For most people it will be you; the recoverer, that counts. Sometimes it will be parents or partners. Either way, those calories need to be counted because after an eating disorder, people have unreliable hunger cues. The body has gone so long without food that it has repressed the signals, and so it can take a long time for reliable hunger cues to return again and for the body to learn to expect food and give signs as to when it needs it. This can mean that eating can feel like a chore to some. It could mean that you will have no appetite and feel too full, but it is important to ensure that you continue eating adequately regardless. It could mean that you feel really hungry sometimes, but other times have no appetite. Respond to any hunger or cravings that you have, and continue eating enough even when you don’t have an appetite. You may have reliable hunger cues straight away, which would be great and would lead you to eat what you need to eat in order to recover. Responding to mental hunger is also really important. Mental hunger is just another signal from the brain to tell you that you are hungry. All signals come from the brain, and it is crucial to listen. So if you don’t feel the physical signs of hunger but are wanting or craving food, then it is necessary to listen to that signal and respond to it – always.

So how are you going to count calories? I would advise staying away from apps such as MyFitnessPal, as they can be incredibly triggering due to the fact that they try to suggest restrictive amounts to eat, and they are an app focused on weight loss. You could just use a ‘notes’ app and count it up yourself and keep the number on record for the day there, or you could write ‘500’ as many times as adds up to how much you need to eat on a sheet of paper or on a notes app on your phone, and just cross it off every time you reach 500 calories. This can mean that you know you are getting closer to your goal but don’t need to count the number if not thinking of the number helps. If your parents or partner are very involved in your recovery, they could do the counting for you if this is possible and more beneficial for your recovery.

Calorie counting can be triggering for many people, but the alternative of under-eating is much more harmful. Under-eating – which many people in recovery will do due to unreliable hunger cues if they do not count calories or have them counted for them – will mean that the body cannot heal. Mental and physical recovery are interconnected, so if the body is not getting enough energy, this will also impact on mental recovery also. Under-eating means that neither mental nor physical recovery will be able to take place, so counting calories until your hunger is reliable is a necessity. This is one habit that will have to be saved until a bit later to break – which is okay, because there are many habits and thought processes to manage, change, and break, and there has to be something that is saved until last (or later on)!

So you’ve been counting calories for a while and making sure you that you get the energy that your body needs. How do you know when you can stop counting and start going by hunger? When you start feeling like your hunger is happening in a reliable way which is consistent with when you should be eating and how much you should be eating, you can start thinking about testing out that hunger to make sure that it is naturally bringing you to the amount you need. A good way to test how reliable your hunger is, is to write out everything you eat for a week (or two weeks), and then count it up for each day, add it all up to get the total amount, and divide it by seven (or fourteen). The average figure should come to around the amount that is suggested as the minimum for you to eat during your recovery (this is around the amount that you should need forever). If it is three hundred to four hundred calories below that total, then I would really suggest that you continue to count calories as your hunger signals are likely to be unreliable. Most people will naturally and intuitively eat the amount recommended for them, or close to it, as this is the amount that an energy-balanced body needs each and every day. Some people do have hunger that is below or above the average (for example, someone who is expected to need 3000 calories for their age, gender, height, and activity levels could find that they naturally eat 2400, or 3600), and that is absolutely okay. However, if you are eating more than three hundred to four hundred less than what is recommended as adequate, it is more than likely that it is your hunger cues that are unreliable and you still have a little way to go before they are back to normal. If, say, 2400 calories is your normal hunger, eating 3000 for while longer will not have a negative effect on your recovery process, and will not have an impact on your weight. Your body will adapt to deal with the excess energy by putting it to good use (e.g. to continue repairing your body) or the metabolism will speed up to burn it off. (As a side note, when you are adding up your calories for those tester seven days, if one day has a really low amount, and another a higher amount, for example, 1000 calories one day and 4500 the next, this is a sign of unreliable hunger cues, even if the average does come to around the amount suggested for you. As a second side note, if you are consistently eating well above and beyond the minimum you require for recovery, your hunger cues are working and you are experiencing extreme hunger or higher energy needs still, which is totally normal for recovery).

So let’s say your hunger cues seemed reliable, and testing this out has shown that they are, now what? You can start trying to eat intuitively, but you will need to keep reassessing yourself to make sure your eating disorder is not sneaking in and manipulating the situation. It is important that you eat what you want, when you want, and don’t let the anxiety of stopping calorie counting come out in other ways, such as restricting certain foods types or resisting eating something you want because you are worried you are eating more now you have stopped counting. It is going to make you feel more out of control, but it is important to continue onwards, and not use any other behaviours.

But how do you go about stopping counting calories? Calorie counting is a hard habit to break. It can become so ingrained in you that it can happen even without consciously thinking. There will be different things that work for different people, but here is a list I put together with some suggestions about how to stop counting:

  1. Get yourself and your family to put labels over the calorie amounts on packets etc. This can deter you from looking and also remind you when out of habit you try to check that your goal is to not look and not to count.
  2. Get your family to serve you at dinner time, to challenge skewed perceptions of portion sizes, and to learn to relinquish control over amounts.
  3. Stop measuring foods or liquids.
  4. Eat intuitively for one day (or even one meal). In a week or so, try doing it for two days (or meals). Work your way up until you can ditch the habit altogether.
  5. Visit cafes, restaurants, cinemas, and other places that are uncaloried to get you used to eating meals where you don’t know the calories to face that anxiety and start to overcome it. You can then start trying to do this at home and challenging yourself there.
  6. Listen to your body and its signals (this is also something you should start doing as soon as you get into recovery, even when you are counting calories). Follow your body and tune in to what it is telling you, rather than going by calories you’ve already eaten today or any other calorie “rules” you are sticking by. Start learning to listen to mental and physical hunger, and also learn that you can also eat when you are not hungry if you fancy it.

There are only six suggestions here, and there will be countless other things that can help. If you have any tips that helped you or someone you know, write them in the comments below so that others can benefit from it too!

Counting calories and not counting calories are both big parts of the recovery process, and both relevant at different stages in your journey. Again, make sure that you are not using compensatory behaviours when you start trying to eat intuitively and stop counting calories, such as eating smaller portions, cutting out calorie dense foods, or not drinking liquid calories, out of anxiety. Learning to eat intuitively without compensating due to anxiety is a big part of recovery. You need to learn to eat what you want, when you want, without letting your ED get on the stage with you. Make sure it is not running the show, or even making compromises with you. It doesn’t have a place in the life that you are creating for yourself. This life is yours, and yours only.

Celebrating Three Years Since Choosing Recovery

3 years 5

TRIGGER WARNING – this post shows images of my body during my eating disorder, as well as images of my recovered body*. Please do not look at this article if these are images that are likely to trigger you.

In the last three years (and a bit), I have come further than I ever thought I would. Just over three years ago I was a suicidal, starved, insane mess of a human being. I was throwing glasses across the room in anger because my partner at the time had turned around my horrible self-reminders not to eat that I had plastered around the house, and had instead written lovely messages on the backs on them. Just over three years ago I was screaming at him because he put a dash of milk in the scrambled eggs. I had intense urges to eat food off the ground because my body was so hungry. Each day was all about filling out the time until I was “allowed” my next measly portion of food. My life revolved around the number on the scales. Everything I did was for that number to decrease. I walked around with my brain feeling foggy, my body weak, and put it through intense and draining physical exercise anyway. I was a walking corpse. I wasn’t alive. I was merely existing.

It took me a couple of months of uhmming and aahing to really choose recovery. I was uncertain. I was scared. I was in denial about having to gain weight in order to be healthy and happy. But eventually I got there. Gradually I solidified my decision, and I although I had ups and downs (understatement of the year), I never really looked back. I had many, many, many moments where I said to myself “I’m done! I’m going to relapse!” but I would cry it out and keep on going anyway.

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A year into my recovery, I made the photo above. If you know me and my blog, you’ve probably seen it before (and I posted it on another post on this website too). The hollow, unfocused, red-ringed eyes had been replaced by bright, shiny ones. My grey, matte skin now glowed. My smile didn’t seem stretched, and the happiness showed upon my whole face, rather than looking tired and empty. I love the comparisons. It always shocks me, and it always reminds me how terrible I looked then and how healthy I look now. It always reminds me of how far I have come.

3 years 3

My hair is shiny and soft now, not falling out, and not desert dry. After two or so years in recovery, it suddenly grew really fast and is now really long and I love it. I now engage in the world: my senses aren’t dulled due to starvation, and I take in what is around me. I am fully present when conversing with friends and thoughts of my body don’t cross my mind when I am with them, when before I was utterly distracted by how my body looked in that moment. I feel strong, rather than feeling like I am going to pass out at any moment. I feel like I am really in the world, rather than miserable and alone in my own harrowing personal nightmare.
dani and sarah
During recovery, my personality that had been smothered by my eating disorder emerged, stronger than before. During the first two years of my two and a half years in recovery, I grew more than I had ever done in my life. I established who I was and what was important to me. I developed hobbies and interests that I had never had before, whilst regaining my love of old ones. With help from feminism and the body positivity movement, I felt empowered and impassioned. I found my drive and my purpose, and I established my worth as a person inside my own head. In simple words, I now feel solid. I feel strong.

3 years 2

My eating disorder starved me. I lost myself, not just my weight. My relationship disintegrated. I couldn’t concentrate around my friends (although, unlike a lot of others with eating disorders, I managed to maintain my friendships). I didn’t do anything without thinking about losing weight. Recovery gave me back my sanity, and my ability to function within the world and within relationships. I regained weight, and I regained myself. Unfortunately, my relationship came to an end six months into recovery, but I now know I will be able to have a healthy, happy relationships without my eating disorder destroying me, and in turn, destroying my relationship.

3 years 4

For me, sleep was first an escape from the pain of the life I was living when my eating disorder was active, but after a while, as my body became more and more starved, it became impossible to sleep. I would be thinking over and over about my “meal plan” for the next day, and would find it really difficult to fall asleep. When I did, it was food that I dreamed of – that, or gaining weight – and I would wake up in fits of anxiety, or stroking my hipbones; a bizarre habit that occurred in the worst period of my eating disorder. One of my favourite things about being healthy is being able to sleep properly. Resting is so important to me now, and such a relief.

3 years 13

Giving up exercise was something that I really struggled with during recovery, and was something that I relapsed with two or three times. Once I’d started eating and my survival instincts took over, restriction wasn’t something I wanted to engage in again (even though my eating disorder kicked and screamed against that thought), but exercise was something I could do without having to feel hungry all of the time but could still burn calories and feel “healthy”. Even though my weight didn’t change whether I exercised or not, I still had the severe compulsion to work out because I felt so anxious and guilty if I did not. But even though I didn’t have to deal with being hungry all the time, exercise made me so utterly exhausted that I could not even sit up in bed with my laptop on some days. I had to lie down instead. Eventually, I was able to cease exercise until I was healthy enough both mentally and physically to be able to do what I now like to call “recreational activity”. I walk a fine line in choosing to be active in remission, but I have my “red”, “amber”, and “green” types of exercise so I know where I am with it, and I’m constantly evaluating how I feel and how much I’m doing. I see the activity I do as enjoyment rather than doing it for my body – the health benefits are secondary for me. Having fun comes first and foremost in the choice to do physical activity, and I think it should be that way for everyone.

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The picture above is me today. I am now over 8 months into remission (full recovery). I feel strong and healthy and confident. I have bad and good days with my body, but I more or less accept it for what it is now. Today was a good day, and I feel powerful as a person. I’m about to have a delicious dinner with my family, on holiday, with a view of the sea. This evening I am going to a bar to have cocktails with my brother. And it won’t even matter to me how many calories any of what I have consumed today has.

I am enjoying being me.
3 years 6

*The reason I have included photographs of myself when I was ill is because for me, it’s an amazing transformation. Recovery should be equally about mental and physical recovery – you can’t have one without the other – and I wanted to show both, because for me, my experience with weight gain was a huge part of my recovery. I can only show my physical recovery through photographs, and my mental recovery through expressing it in writing. This article is not about the process but about the comparison as to how I was then to how I am now. I also wanted to show that it is possible to gain a significant amount of weight and look very different and be able to accept that. My body and the changes it made throughout recovery were hugely significant to me, so to be able to show that comparison and say that I made those changes to my body and I got through all the self-loathing, guilt, and anxiety, and found my way to accepting my body as how it looks now is incredibly important to my journey. Some people may not agree with my choice to include photographs, but that is why there is a trigger warning. That was my body, and this was my journey, and I want to express it in the way that is significant to me. 

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.

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:

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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?

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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!

Diagnosing Anorexia Nervosa VS EDNOS: What Does the Weight Criteria Really Mean?

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Making a distinction between EDNOS and Anorexia Nervosa is a tricky one when it comes down to the Atypical Anorexia Nervosa (a type of EDNOS) side of things. There are those that adhere to the strict weight criteria for the diagnosis of Anorexia Nervosa (even though there is now no specific cut off point in the DSM-V), and there are those that use it as a guideline. The argument on whether or not a specfic weight is required or not for the diagnosis of Anorexia Nervosa is rife across the eating disorder communities, so I decided to do some research on what the medical community has to say on the matter.

According to the DSM-5 criteria, to be diagnosed as having Anorexia Nervosa a person should display:

  • Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health) .
  • Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight).
  • Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

The Subtypes of Anorexia Nervosa are: restricting type, and binge-eating/purging type.

(I should also first mention that the DSM-V has already been widely criticised, and The National Institute of Mental Health withdrew their support for the manual, stating that “patients with mental disorders deserve better.”  Another thing to consider is that the cut off point for what is a healthy BMI varies from medical institution to medical institution. Many use 18.5 as the cut off point. Others use 19. My pharmacist had a chart on the wall that stated that a normal BMI was between 20 and 25 (it also states that here). So that already can create problems when there is no consensus between medical communities on what is underweight. You can go to one doctor’s surgery and be told you are underweight and another where you are told you are not. Really, we should just be going on each personal individually, and using these charts as a guide.)

To start with, Kate Donovan wrote “Problems in the way we diagnose anorexia” – a blog post exploring the weight criteria when we still had the DSM-IV – which is relevant because Anorexia Nervosa is still being diagnosed using an outdated weight criteria.

The reason this is so important is that Atypical Anorexia Nervosa and Anorexia Nervosa are barely distinguishable – so why are there two different diagnosis’s dividing the two when they are the same disease and both require extremely similar treatment which only differs in terms of the individual rather than the label? Results of Jennifer Thomas’s study (The relationship between EDNOS and officially recognized eating disorders: meta-analysis and implications for DSM) indicated that EDNOS did not differ significantly from AN on eating pathology or general psychopathology, and “moderator analyses indicated that EDNOS groups who met all diagnostic criteria for AN except for amenorrhea did not differ significantly from full syndrome cases.” (Jennifer Thomas is an assistant Professor of Psychology at Harvard.)

In another of her studies (which is about the criteria in the DSM-IV “refusal to maintain body weight at or above a minimally normal weight for age and height e.g. weight loss leading to maintenance of body weight less than 85% of that expected”), she writes

“Although the 85% weight cut-off is intended to represent a ‘suggested guideline’ for diagnosis (APA, 2000, p. 584), investigators who enroll eating disorder patients in clinical trials (Dare et al. 2001; Powers et al. 2002) and insurance companies that determine treatment eligibility typically adhere to this percentage when assessing underweight. The 85% criterion is also frequently used to calculate AN prevalence in epidemiological studies (Walters & Kendler, 1995; Garfinkelet al. 1996), which inform the perceived public health significance of the disorder. The widespread use of the 85% criterion probably reflects a desire to standardize diagnosis across diverse settings.”

She also states;

“Data from clinical and non-clinical samples suggest that eating disorder not otherwise specified (EDNOS) is the most prevalent of DSM-IV eating disorders, and individuals who meet all criteria for AN except the weight cut-off represent a common subtype of this group (Watson & Andersen, 2003; McIntosh et al. 2004). A computer simulation of 193 eating-disorder treatment seekers indicated that the prevalence of AN would increase significantly if the weight criterion were relaxed from 85% to 90% of EBW (Thaw et al. 2001). It is therefore likely that if some clinics use more lenient methods of calculating EBW, they will diagnose a greater proportion of their patients with AN and a relatively smaller proportion of patients with EDNOS, even if they consistently apply an 85% cut-off.”

Jennifer Thomas also makes an important point regarding diagnosis and treatment regarding weight cut off points:

“The finding that investigators use different weight criteria for AN has important implications for eating disorder diagnosis, treatment, research and insurance reimbursement. Our results raise the possibility that a patient of a particular height, weight and symptom profile could receive a diagnosis of AN at one treatment center and a diagnosis of BN or EDNOS at another, and be eligible for one investigator’s AN treatment outcome study but not another. On average, discrepancies are possible within a 15-lb weight range for females and a 25-lb weight range for males, and could occur even if the assessing clinicians at each treatment center referred to the same DSM-IV criteria to assign diagnoses. If each clinician then attempted to recommend an evidence-based treatment, the patient diagnosed by the stricter weight cut-off and therefore classified as BN or EDNOS might receive out-patient therapy whereas the patient diagnosed by the more lenient weight cut-off and therefore classified as AN might receive a more intensive intervention (e.g. in-patient care) because of the perception that he or she is more underweight.”

She also made the following comment on a post by Science of Eating Disorders (‘Are There Any Meaningful Differences Between Subthreshold and Full Syndrome Anorexia Nervosa?’):

“I share your frustration with the 85% EBW guideline — it’s not only arbitrary but inconsistently applied (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847836/). Interestingly, the DSM-IV Work Group never meant it to be a “cut-off” (just a guideline), so it’s a good thing it’s being omitted from DSM-5. My work also suggests that EDNOS is typically just as severe as AN and BN (http://www.ncbi.nlm.nih.gov/pubmed/19379023), and clinically I think too many patients find their suffering invalidated when they are diagnosed not with a specific eating disorder, but an acronym. I also agree with you that DSM-5 represents a big improvement (especially the inclusion of named subtypes like purging disorder)…”

The post by Science of Eating Disorders (which is linked above) talks about a study conducted by Daniel Le Grange and colleagues, published in the European Eating Disorders Review, where they compared eating-related and psychopathology measures between 59 anorexia nervosa and 59 subthreshold anorexia nervosa women, and found that there were no differences between the two other than the bingeing and purging frequency, which was higher in the AN group, and body checking behaviours, which was higher in the EDNOS-AN group. They said:

“There is little evidence that participants with EDNOS-AN were any different from those with AN. Therefore, our results confirm the now accepted notion that menstrual status is probably not a helpful diagnostic marker for AN (Attia, Robero, & Steinglass, 2008) and also challenge the generally accepted cut point of 85% of ideal body weight (or BMI 17.5 ) for a diagnosis of AN.”

We know that the weight threshold that is used so rigidly by some can cause massive problems for those seeking treatment: many insurance companies and inpatient facilities will only accept those meeting the “anorexic BMI” criteria – even though the specific weight criteria has been removed with the publication of the DSM-V. We also know that the DSM-V is to be used as a guide, and that the “anorexic BMI” is also a guide, not an absolute. There is no weight that you MUST be to be diagnosed with anorexia nervosa.

What I’ve seen from observing both the reactions from some who have suffered from eating disorders (specifically those who have, or are in recovery from, anorexia nervosa) and doctors in response to the idea that you don’t have to meet the weight criteria (that actually doesn’t exist any more in the DSM-V) of 17.5 to be diagnosed with anorexia nervosa, it is those with anorexia that tend to become outraged when it is suggested, whereas all different doctors have different opinions, many leaning towards using the manual as a guideline. Medical professionals that I have spoken to recently do not believe in weight criteria rigidity being exceedingly important to the diagnosis of Anorexia Nervosa. I recently spoke to a doctor in the UK, and a medical director in the US. Both told me that the DSM-V (and the ICD-10) are guidelines, and are to be used as such. When asked about anorexia, EDNOS, and the weight criteria, the US medical director said it is subjective:

“DSM criteria are not absolute, like many things in medicine with variable presentations, symptoms, and severities. The diagnostic criteria are best used as a guide. Unfortunately some take it too literally (many payors, insurances, etc) will not cover care unless strictly adherent to these criteria. I believe the key is to recognize and anticipate before the process progresses to a unstable or potential irreversible condition…Following strict criteria in my opinion results in delayed therapy of patients in worse conditions.”

In the DSM-V, it states:

“Criterion A requires that the individual’s weight be significantly low (i.e., less than minimally normal or, for children and adolescents, less than that minimally expected).Weight assessment can be challenging because normal weight range differs among individuals, and different thresholds have been published defining thinness or underweight status. Body mass index (BMI; calculated as weight in kilograms/height in meters2) is a useful measure to assess body weight for height. For adults, a BMI of 18.5 kg/m2 has been employed by the Centers for Disease Control and Prevention (CDC) (Centers for Disease Control and Prevention 2011) and the World Health Organization (WHO) (World Health Organization 1995) as the lower limit of normal body weight. Therefore, most adults with a BMI greater than or equal to 18.5 kg/m2 would not be considered to have a significantly low body weight. On the other hand, a BMI of lower than 17.0 kg/m2 has been considered by the WHO to indicate moderate or severe thinness (World Health Organization 1995); therefore, an individual with a BMI less than 17.0 kg/m2 would likely be considered to have a significantly low weight. An adult with a BMI between 17.0 and 18.5 kg/m2, or even above 18.5 kg/m2, might be considered to have a significantly low weight if clinical history or other physiological information supports this judgment. For children and adolescents, determining a BMI-for-age percentile is useful (see, e.g., the CDC BMI percentile calculator for children and teenagers). As for adults, it is not possible to provide definitive standards for judging whether a child’s or an adolescent’s weight is significantly low, and variations in developmental trajectories among youth limit the utility of simple numerical guidelines. The CDC has used a BMI-for-age below the 5th percentile as suggesting  underweight; however, children and adolescents with a BMI above this benchmark may be judged to be significantly underweight in light of failure to maintain their expected growth trajectory. In summary, in determining whether Criterion A is met, the clinician should consider available numerical guidelines, as well as the individual’s body build, weight history, and any physiological disturbances.”

This means that people need to be treated on an individual basis, and not strictly by a weight criteria.

What I find worrying is that some (emphasis on some) of those with the diagnosis of Anorexia Nervosa feel that the criteria should be rigid: so much so that they actually believe that it is. I would suggest that this is because some can see it as a badge of honour that you only “deserve” when you reach a certain weight. Those with such black and white thinking regarding AN are particularly (and disorderedly) protective of the diagnosis. This only reinforces to those diagnosed with EDNOS that they are “not sick enough” until they have “achieved” that particular BMI. It also reinforces the (untrue) notion that you can only be diagnosed with AN at a certain weight, and this results in the spreading of misinformation.  It is important that we are educated about the facts, rather than going purely on beliefs when we are not medical professionals ourselves. The negative emotional connection some of those with Anorexia Nervosa seem to have to the diagnosis and the “badge of honour” mentality can cloud judgement and rational thought, and become an issue as it invalidates others.

Obviously in no way is this article intended to invalidate those with EDNOS. In fact, I hope to validate the diagnosis more as those with EDNOS routinely present with symptoms and behaviours that are as serious as AN or BN. My aim was to show that there is barely any difference between those with Atypical Anorexia Nervosa and those with Anorexia Nervosa, and it is my opinion that they should all be diagnosed with the same illness, and any difference in physical symptoms be treated accordingly. Any doctor or professional who is worth their salt will pay attention to the mental and physical condition their patient is in and diagnose that way, or if they have been diagnosed before, they will reassess and treat accordingly. Using the guidelines as absolutes can be extremely harmful, misguided, and unhelpful, and spreading the notion that they are absolutes within the eating disorder community on social media and within our culture in general, is harmful to those seeking help, support, and treatment.