Stumbled across a journal article on Psychological Inflexibility and Symptom Expression in Anorexia Nervosa.. Reading it was like one big “ah ha” moment – picture a cartoon character with the lightbulb above his head. Seriously, I could see myself in pretty much everything they said/proposed.
This is what their proposal is:
“Among individuals with AN, fear of harm and demand for certainty lead to over-reliance on verbally ascribed rules for behavior to minimize ambiguity, avoid mistakes, and provide the semblance of control over aspects of experience that are essentially uncontrollable (i.e., the volatility of the body associated with motivational states such as hunger or affect)…Rules for behavior provide an illusion of safety and certainty, thereby allowing for short-term relief, but at the expense of long-term physical and psychological health which require sensitivity to fluctuations in experience to respond to dynamic emotional and metabolic needs.”
For me, rules for behavior (such as staying under a certain calorie level per day) don’t really provide me with an illusion of certainty because I have experienced these “rules” not working many, many times (ie restricting not leading to weight loss). However, I guess there is still more certainty there than if I didn’t have the rules at all. Furthermore, I definitely do have this demand for certainty that they talk about, particularly when it comes to my body. They elaborate on this further on:
“Individuals with AN behave as if they are at war with their bodies, fighting for dominance or complete control. Inevitably, this is a losing battle. There are far too many fluctuating variables determining the condition of the body at any given moment for somatic states to be precisely manipulated (or “controlled”). For example, consider the factors that maintain energy homeostasis. While the energy demands of the body can be approximated…in fact, these demands constantly vary. Such energy needs are a result of “controllable factors” such as diet and exercise combined with innumerable, “uncontrollable” internal factors that, while contributing to metabolic demands, are inaccessible to conscious manipulation (e.g., degree of muscle repair and growth, energy cost of digestion, etc)….For most individuals, fluctuations in need and bodily experience are par for the course. For example, in times of increased hunger, many people simply eat more to meet this demand. However, for individuals with AN, anxious temperament and accompanying demand for certainty may make this somatic variability intolerable and propel desperate attempts to force homeostasis….Distress from even minor perturbations in somatic experience may contribute to well established behavioral features in AN, such as perpetual error monitoring (e.g., body checking, weighing). These attempts to reduce feelings of fear and uncertainty are a logical, though maladaptive, response when one is trying to control such a naturally volatile system. The result is an extreme state of biological and emotional suppression, a state highly reinforcing for those who demand certainty.”
Yes, exactly. I have a lot of “should” statements in this area – I should have energy after eating and with caffeine, I should be hungry at X time, I should lose weight if I restrict etc. However, the majority of the time those things don’t work out – I am tired after I eat, I get hungry at random times, and I don’t lose weight if I restrict. When those things happen, I end up feeling really hopeless, depressed and fearful. It isn’t so much the weight gain that makes me depressed, it’s more the weight gain when I am not expecting it (ie when I am restricting) that does. The depression, as well as this fear that if I can’t control my body even with the ED behaviors, then what the hell would happen if I didn’t check my weight, count calories etc., just keeps the cycle of behaviors going. Interestingly, gaining knowledge about how the body works from medical school has not made these should statements go away, even though I know intellectually a lot of the adaptive mechanisms the body uses to maintain homeostasis. The irony is that if I could just let up trying to control my body probably nothing would happen except I would be less depressed.
The article goes on to cite several studies that show that recovery is not so much about not having these thoughts, but about being able to not be distressed by them. One such passage is:
“Although the frequency of perfectionistic cognitions did not change, adolescents’ reported decreased distress in response to these thoughts. Importantly, decreased distress [from perfectionistic cognitions] was associated with reductions in dietary restraint and lower global scores on a structured interview of eating disorder symptoms when baseline levels of symptoms were controlled. This is consistent with studies of adults with AN that have reported greater acceptance of negative thoughts and feelings about weight and shape corresponded with ED symptom improvement in the absence of any significant change in the content or frequency of the thoughts and feelings themselves.”
In other words, rather than having the treatment goal of removing the negative thoughts altogether (because let’s face it – who doesn’t have negative thoughts about themselves?) the goal is to be able to accept those thoughts and move on. Accept that my body is going to do what it wants, when it wants, and maybe I should just let it be the guide for awhile.