Depersonalization vs Dissociation

Recently I’ve seen a good article on depersonalization disorder floating around. Like many people, I’d never heard much about depersonalization, despite the fact that I have experienced it for extended periods of time in my life. But when I read this description, I felt both a sense of overwhelming familiarity and also some serious confusion. Because what they were describing was something I had been told was called dissociation.

So just to clear things up, I have researched the differences between depersonalization and dissociation so that you don’t have to. Both of these are surprisingly common experiences that don’t get a lot of airtime and could use more attention. So let’s clarify terms and learn! Huzzah!

 

You can find this full post at Aut of Spoons.

Autism, BPD, Eating Disorders

This is a completely unscientific exploration of connections between a few different diagnoses that has been helpful to think about for me. This will be a long one because there’s a lot to work through, but I think it’ll be interesting.

I’ve started to notice a lot of parallels between autism and borderline personality disorder, and have also seen that eating disorders or feeding issues are incredibly common comorbidities for both of those disorders. I’m curious about why that is, whether there is misdiagnosis going on, and whether BPD and autism might actually be more similar than most people think.

Let’s start with some facts. Autism tends to be coded male. There are far more boys with the diagnosis than girls, and it can be incredibly difficult for girls to get a diagnosis of autism (girls have a much higher age of first diagnosis than boys, and studies that independently measure symptoms found many undiagnosed girls). Some people have even gone so far as to say that autism is an “extreme male brain.”

The diagnostic criteria of autism are as follows:

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text):

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

Specify current severity:

Severity is based on social communication impairments and restricted repetitive patterns of behavior (see Table 2).

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).

4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

Specify current severity:

Severity is based on social communication impairments and restricted, repetitive patterns of behavior (see Table 2).

C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

On the supposedly opposite side of the spectrum is Borderline Personality Disorder, which is far more common in women, and in many ways is the modern hysteria. It’s diagnosed often in women who are seen as unruly or out of control, is an incredibly controversial diagnosis, and is seen as an extreme “female” brain.

The diagnostic criteria for BPD are as follows:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following”:

• Frantic efforts to avoid real or imagined abandonment
• A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
• Identity disturbance: markedly and persistently unstable self-image or sense of self
• Impulsivity in at least two areas that are potentially self-damaging (e.g., substance abuse, binge eating, and reckless driving)
• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
• Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
• Transient, stress-related paranoid ideation or severe dissociative symptoms

So these two diagnoses appear to have almost no overlap. In fact they appear to be complete opposites in some ways (extreme emotional reactivity vs. restricted emotional expression). One of the things that is incredibly common in both of them though is misdiagnosis and stigma.

BPD is so stigmatized that some therapists intentionally misdiagnose to protect clients from stigma. However it also has many overlapping features with PTSD, bipolar, major depressive disorder, schizophrenia, and anxiety disorders. Men are often misdiagnosed with Antisocial Personality Disorder or substance abuse. Autism is often misdiagnosed in women as ADHD, bipolar, depression, anxiety, or OCD. There are a few odd things about these high rates of misdiagnosis, the first being that two disorders that appear to be diametrically opposed could have so many similar misdiagnoses.

If we go beyond the strict diagnostic criteria, the behaviors of BPD and autism can look surprisingly similar, especially when we look at how girls present autism. From a Guardian article on autism in girls and women:

“‘Autism is seen as a male thing, and boys are often physical in expressing themselves when unhappy, whereas girls implode emotionally,’ says [Sarah] Wild [head teacher at a school for autism]. ‘Boys tend not to be interested in contact and friendship, whereas girls desperately want friendship, they become obsessed very easily if they focus on someone as ‘theirs’ – whether a girl or a boy – and they yearn for boyfriends.’

Girls with autism are likely to worry about body image and get very involved with TV series and celebrities, says Carol Povey, director of the NAS’s centre for autism. And there is a clear association between autism and eating disorders, as a report by Cambridge University’s autism research centre, led by Professor Simon Baron-Cohen, notes.

While boys tend to be diagnosed as young as three, late diagnosis can be a problem for girls, whose behaviour can be dismissed as “teenage hormones”. ‘They are full of emotion and implode into isolation and depression if things go wrong,’ says Wild. Things seem to start going really wrong at about age 13, she says, when many become school phobic.”

These differences end up creating a very different picture of autism in girls and women than in men and boys, one that looks far more similar to BPD. Both diagnoses can include serious self harm or suicidal ideation, controlling behaviors (especially in relationships), black and white thinking, feeding issues/eating disorders, trouble with social situations (including anxiety), depression, and sensory issues. For those with BPD, life often feels like it’s lived without an emotional skin, and that can come with strong reactions to sensory stimuli. For those on the spectrum with strong sensory seeking needs, behaviors can start to look impulsive. BPD tends to be diagnosed during the teen to early adult years, and girls also are likely to get an autism diagnosis in later childhood to early adulthood. And in both cases, the lack of a diagnosis can be a huge source of frustration, confusion, depression, and welled up emotion.

Another similarity is the diversity of presentations of each of the two disorders. Because of the way criteria are structured within BPD, it’s possible for two individuals to both have the diagnosis and only have one overlapping trait. Autism is similar in that it affects multiple areas of functioning, which means there are thousands of different permutations of symptoms and behaviors that can appear.

Both BPD and autism are distinctly underdiagnosed, with more men having trouble getting a BPD diagnosis and more women struggling to get an autism diagnosis. From http://psychcentral.com/news/2009/05/25/borderline-personality-disorder-difficult-to-diagnose/6070.html

“The study included 70 adults who met the criteria.

All had been given a diagnosis from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in the past and had also seen a mental health professional in adulthood or been prescribed a psychotropic medication.

Yet, 74 percent of the patients who met the criteria for the condition had never been diagnosed with borderline personality disorder in the past, despite an average of 10.44 years since their first “psychiatric encounter.”

What’s hisface examines many of the ways that BPD and autism can look similar: explosive anger or meltdowns, intense relationships mixed with difficulty getting close to many people, serious miscommunications. If you look at an individual who self harms, has serious anxiety and anger issues, attaches to one person and has difficulty connecting with others, is incredibly sensitive, and who sometimes engages in intense and seemingly odd behaviors to fulfill stimulation seeking, would you assume BPD or autism? Because it could go either way.

Of further interest is the fact that BPD has incredibly high rates of comorbidity with eating disorders. There is good evidence that women with anorexia have autistic traits, and that individuals with autism are at high risk of developing eating disorders. Some studies have even shown comparable levels of emotional processing and executive functioning between those with anorexia and those with autism. Feeding disorders are also incredibly common with autism.

Most of my interest in autism came initially through the lens of eating disorders. Difficulties with textures, rituals around food, OCD, and other highly controlling behaviors are incredibly common with eating disorders. These kinds of control oriented behaviors are hallmarks of autism.

Control is not a word that most people associate with BPD, but I’m not sure why. In my experience, the more out of control someone feels, the harder they try to cling to control. All of the BPD symptoms that I have are the things that have pushed me to develop intense rituals and rules for myself, out of fear that any deviation will lead to complete chaos. Others who have comorbid BPD and eating disorders that I have spoken to (entirely anecdotally) have also felt that they use the control of the eating disorder to cope with the intensity and chaos of the BPD.

Also anecdotally, many of the folks that I’ve talked to on the spectrum talk about having rituals so that they can feel more in control when they are overwhelmed by extreme sensory input or because of difficulties with theory of mind. The OCD tendencies that I have and the information that I’ve read about OCD indicates that rituals, control, and rigidity in OCD also stems from a fear of being out of control, a fear that the world could change or fall apart or go wrong in some unknown or drastic way if you do not engage in the rituals. Chaos is often what leads to extreme control.

For those on the spectrum, that often comes in the form of social interactions that make no sense and sensory input that is overly intense. I’ve also heard many on the spectrum say that in contrast to the assumption that they have no empathy, they actually have an excess and simply can’t figure out how to make other people happy or feel better. The emotional elements of this explanation ring familiar to someone with BPD: other people seem unpredictable, swinging from perfect to evil in a day. You just want to be good enough, kind enough, the best possible person so that no one will be sad or unhappy or angry or want to leave you.

Especially of interest to me are the sensory elements of BPD, which I could find almost no research about at all. BPD is well known for coming with extremely strong emotions, but in my personal experience, that often comes with sensory sensitivities as well. Emotions aren’t just experienced in the head: they’re experienced in the body. I have to regulate my food and sleep extremely carefully in order to be functional, I have strong reactions to textures, and as someone who is often overwhelmed by my emotions I can’t handle crowded, loud, or otherwise overwhelming places very well.

And when you add in an eating disorder to BPD, you get some serious sensory sensitivities in the form of taste, smell, and touch (often aversions). All together it makes me wonder if BPD and ASD are all that far apart, or if they both might be pointing to a variety of disorders that look similar but have different etiologies. I wonder if some of those disorders overlap, and gender is playing a big role in who gets what diagnosis. I wonder whether concepts like a sensory diet could be helpful for those with BPD or whether learning concrete social skills like setting a boundary could be helpful for those with ASD.

Obviously all of this is speculative, and it seems unlikely that BPD and autism are the same thing. But I do think that the strict delineations between personality disorders and autism, or simply the received knowledge of which disorders are “like” which other disorders might not be helping folks get accurate diagnoses or useful treatments. There are more crossovers than appear at first glance.

10 Real Reasons Not To Restrict

One of the blog posts in my archive that most consistently gets hits is 10 Real Reasons Not to Self Harm. I’ve had multiple people tell me that it was a useful post for them in some way, and I’ve found myself referencing it when I’m feeling really crappy and I need some reminders from my slightly more stable mind about why I shouldn’t self harm.

Lately I’ve been feeling some urges to restrict again, and so in the spirit of 10 Real Reasons, I want remind myself and others what actually sucks about giving in to eating disorder temptations and restricting your food intake.

1. This might seem super obvious but it’s really easy to forget when you’re in a serious restricting place. Food tastes good. Not only that, but it’s hugely comforting to eat a warm meal or to have something that reminds you of childhood or a good time in your life. You’re denying yourself something that’s super fucking awesome by not eating. I know you probably know that, but I just thought I’d mention it.

2. Most people who restrict heavily like to try to convince themselves that not eating doesn’t actually affect their energy, mood, or thought process. Let me just take a moment to call bullshit on that because physiologically there’s really no way for you to have a good level of energy and clear thoughts when you aren’t giving your body and brain enough calories to fuel them. When you eat food you can do more stuff. Stuff like creating great art or being with the people you love or fighting the patriarchy or whatever the hell it is that makes you happy.

3. Do you know how painful it is to sit on things when your ass is bony? It’s very painful. See also: hugs, leaning against things, sex, cuddling, and interacting in any way with the world. Don’t starve yourself. You need the extra cushioning. It makes the world less hurty.

4. You can lie to me and tell me that you’ll feel worse after you eat. And yes, it’s true you might feel guilty or anxious. But there’s this thing called biology and that means that when you don’t eat your mood tanks. Have you ever seen a cranky toddler? Have you ever tried giving that toddler food and seen them suddenly become perfectly fine? We are all the cranky toddler. Eat the food. Feel better.

5. Do you know what people do when they want to be together? They eat. Food is social. Food connects people. Food is how many people express care and affection. When you don’t eat food, you are cutting yourself off from other people, whether you intend it to be that way or not. That is one of the suckiest things about restriction, and it leaves you feeling pretty shitty.

6. Here are some scary facts: when I stopped restricting my ring size, shoe size, and boobs all increased slightly. Do you know what kind of malnutrition it takes to shrink your feet? The kind that will eventually kill you. Keep your feets and hands the sizes they were meant to be. Don’t starve yourself.

7. Restricting may seem like it’s ignoring food, but it usually comes with obsessive thoughts around food. Your life shouldn’t revolve around food. There are a thousand other things you could be doing with your life than thinking about food and worrying about food. Even if you’re avoiding food, you’re still using up a lot of emotional energy and willpower, as well as causing some serious decision fatigue that will mean you’ve got less reserves for every other thing you need to do in your life.

8. Do you consider yourself a feminist? Do you think women should be equal to men, or shouldn’t have to feel all sorts of unnecessary pressures to be beautiful? I’ve noticed that the more the people around me buy into the ideas that they need to eat less, they should be quieter or prettier or more conventional, the more I feel pressure to do so. Even if you think that you’re only impacting yourself by restricting, you’re sending a tacit message to all your friends and acquaintances that you think you should be living by the patriarchal laws that tell women to be skinnier, quieter, less, smaller. You’re taking up less space when the strongest thing for a feminist to do is stretch out and take up as much space as possible.

9. I want you to imagine that your best friend wasn’t eating on a regular basis. Would you ever tell them that this was a good plan? No? Why are you treating yourself worse than other people? It can be incredibly hard to accept that you deserve the same care that other people do or that you’re allowed to take care of yourself (we’re all supposed to just self-sacrifice constantly and hope someone else takes care of us right??) but if you think extreme restriction is bad for the people you love then you gotta accept it’s bad for you (and also start including yourself in people you love).

10. It’s so fucking boring. Jesus christ is restriction boring. It’s lonely, it’s exhausting, and you end up sitting around just staring at walls for most of your life (with some extra crying jags for funsies). Planning your life around NOT doing something is actually the stupidest thing ever. Imagine instead planning what you DO want to do. It’s so much more interesting! You actually do things! You leave your room! You engage with the world! It’s great. I don’t think I’ve ever felt less interested in the world than when I was restricting because my world was entirely sitting around fighting with myself about whether or not to eat. Bo-ring.

Recovery In a World of Triggers

It’s extremely common for people with eating disorders to relapse at least once after feeling as if they’re in recovery or on their way to recovery. Some stats put relapse rates as high as 80%, although with more research on good treatment and long term support for people with a history of eating disorders, it’s likely that the number will go down. But unlike lots of other mental health problems, eating disorders live in a place where the bad behaviors are often praised, and triggers are basically everywhere all the time.

It’s astounding to me that anyone manages to recover at all. I’ve been doing fairly well for about six months, but the longer I spend away from the eating disorder, the more I realize how many unhealthy messages there are all around me. I recently had a conversation in which someone who was well aware of my eating disordered history and who brands themself a skeptic and scientifically literature person suggested that a diet of 1200 calories was an appropriate form of weight loss. Almost every day I hear people talking about how unhealthy it is to eat sugar or carbs or gluten or really anything. No matter how many times I try to remind myself that what’s important is eating food that tastes good to me and eating enough food that I feel full, I am constantly and every day reminded that being hyper aware of diet seems to be synonymous with health.

And yes, there is good evidence that being at a mid range weight, not eating tons o sugar, and getting decent exercise are good for you. The problem is how to interpret that statement when your brain is built for all or nothing thinking and perfectionism, for guilt tripping you and punishing you. How do you find any sort of middle ground between “I am allowed to eat what I want” and “I should try to eat in a healthy manner”? This to me is what makes eating disorder recovery so hard. There is no cold turkey to eating disorders because food is always going to be part of your life, which means at least a few times a day you’ll be thinking about the thing that ruled your mind for so long.

In addition, there’s tons of conflicting information out there about what’s healthy. Even for someone who doesn’t have an eating disorder, sorting through the morass of studies and recommendations can be incredibly difficult, and reading about diet studies can be extremely triggering for someone with a history of an eating disorder. That means most of us just want someone to tell us what’s right, what’s ok. No one can and no one will, so instead we’re surrounded with a thousand different messages and left reeling about what is or isn’t appropriate food behavior.

The unknowing is almost more triggering than the obviously pro-skinniness, pro-dieting messages. The deep uncertainty about whether or not your weight is too high or too low, your diet is too unhealthy or too many calories or too few calories, or not enough veggies, that gets into your mind until you just want the clear rules again. Unlike nearly any other mental health problem, eating disorders circulate around something that’s considered completely acceptable to comment on publicly: food. And it’s a conversation that everyone wants to have, so no matter how you try to avoid it, you have a coworker who says “Oh I’ll be bad and have a cupcake” or a family member who says “I’m down 15 pounds!” in a tone of pride. Each time you try to retrain your mind to erase the disordered messages that say “skinnier is better”, someone else comes along and nonchalantly dismantles your hard work.

Perhaps worse is the fact that many people seem to believe that choosing a “this works for me” approach is unacceptable when it comes to eating. You must be doing what is the most healthy, backed up by evidence, best diet ever or you’re not healthy at all. That means that for someone who has an eating disorder and might have to take some shortcuts (like: if I feel hungry for x food I let myself eat x food so that I get enough calories), their (perfectly logical and healthy) choices are derided as illogical and unhealthy. Some of us know that we engage in unhealthy behaviors and have to accept that to get food in our bodies at all. Some of us need to ignore some of the research to convince ourselves that eating more than 1200 calories a day is necessary. Some of us need to be irrational in order to be healthy, and that’s ok.

On top of all of that, you carry your biggest trigger around with you every day: your body. The changes that happen in your body, even if they’re completely natural, are extremely noticeable to a brain that’s used to nitpicking every ounce of fat. The weirdest things will set you off. I found yesterday that I couldn’t fit into a pair of shoes that had been in my closet since last fall, and that my ring size appears to have changed. These are tiny little reminders that I’m moving into uncharted territory, things to be feared.

All of this is to say that I understand why the relapse rates of eating disorders are so high. I hate blaming diet culture for eating disorders, since a mental illness is not just a diet, but it is true that all the conflicting and horrible information about healthy eating has serious impacts on people trying to bring their eating back to a reasonable middle ground. The good news is that there are people who have managed to recover and stay healthy. The good news is that we’re allowed to set boundaries, remove ourselves from conversations filled with diet talk, block the hell out of triggering websites and ads. The good news is that we’re entitled to our own health and well being, no matter what anyone else says about the appropriate way to eat.

You Can’t Turn Off An Eating Disordered Brain

Massive trigger warning for eating disorders

For about the past nine months I’ve been feeling pretty good when it comes to my body and my food intake. I still have a few hangups, mostly surrounding times when I should eat, but overall I was getting a decent number of calories and feeling fairly energized. I had stopped thinking about what my body looked like every day, and I had even stopped adding up the totals of what I had eaten each day to try to decide if I was allowed another item (or if I needed to go work out).

It was a massive relief to not have those scripts playing in my head anymore. But recently, somewhat out of nowhere, they’ve started to play again.

I have a lot more tools available to me now. I have more friends to ask for help, a better idea of what I want out of my life and why an eating disorder isn’t compatible with that, a fuzzy kitten to distract me, and a variety of strategies about what makes me feel good in the moment, but none of these things have managed to turn off the voices or the accompanying anxiety. They are enormously helpful when I need to choose a better behavior than restriction, purging, or overexercise, but no matter how often I try to ignore the bad suggestions my brain keeps giving me, it comes back louder.

This is what a lot of people refer to when they say that you never really recover from an eating disorder. The disordered brain will linger on and on and on. And while outsiders might suggest distracting yourself or challenging the thoughts, what they don’t understand is how incessant it is. When you wake up in the morning you wonder about what you’ll eat that day and think about whether yesterday was a “good” day (ran a calorie deficit). You go to put on clothes and are left with the quandary of what fits and what doesn’t, what you can convince your brain is acceptable. You go outside and now it’s the comparison game, who’s smaller than you are, who will see you as acceptable, does everyone see how big you are or do they care?

It goes on endlessly. You cannot turn it off (or at least no one has figured out the magic switch yet except constantly choosing a different behavior and working to focus on something else).

What no one tells you about jerkbrains, whether they’re eating disordered or OCD or depressed or anxious is that they will exhaust you. They don’t tell you that the worst part isn’t the full on meltdowns, but the normal days where you thought you were ok but instead have to spend half of your energy fighting with yourself.

It’s discouraging. While it is realistic to know that someone with a disorder that is highly linked to genetics will probably always have to be on the lookout against a recurrence of symptoms, it makes life feel like a neverending Sisyphean endeavor, even moreso than it might for someone who just has to get out of bed and drag themselves to the office each morning.

Even writing this feels like a repeat of things that I’ve said far too many times. It certainly puts more importance into the question of whether genetics are destiny. But pushing against all of the woe and angst and “determinism means it just doesn’t matter!” is the fact that I know I have changed. The eating disordered brain remains, but there is something in there or in me that can adjust. I make different choices, and the lows come further and further apart. I hate inspiration porn, especially when it comes to mental health, so I have to admit that I have no idea if there’s a relapse in my future or what it means for the quality of my life that self hatred is an essential ingredient of every day. But I am also done with wallowing in the unhappiness, so I also have to say that I have hope. There is the possibility of joy.

Between A Rock and a Hard Place: Triggers

Yesterday I was hanging out with my partner’s family having lunch and chatting. I generally like Partner’s family, and they’re very kind people. But I’ve only known them for a few months and I haven’t established a very close bond with them yet. That means they’re mostly unaware of my mental illness. It’s not uncommon for people with mental illnesses to be around others that have this level of acquaintance: you know them, you care about what they think, you respect their opinions, and you want the relationship to grow. But they don’t know about your mental illness.

Most of the time that’s totally fine, especially since it’s not too hard to decide that if someone is a total butthead about mental illnesses and runs around spewing stuff like “it’s all in your head” or “just smile more” you can decide that you simply don’t want to invest in the relationship and stop hanging around them. But sometimes you end up in a circumstance in which someone that you want and need to build a relationship with inadvertently starts triggering you.

So yesterday when the conversation turned to calories and weight loss, I really wasn’t sure what to do. These conversations are nearly always triggering to me, to one degree or another. Sometimes I can keep my reaction under control, but usually it means that I’ll spend the next hour to day thinking about calories and weight loss and fighting with myself over my own caloric intake.

What do you do when you’re in a situation in which you can’t disclose your discomfort without outing a whole other pile of things, but you can’t leave without harming a relationship? Are there tools available? Sure I could have set a boundary by just saying “Hey, I really don’t think weight is that important. Could we talk about something else?” or just changing the subject, but when you’re not in a position of power or comfort, that can be extremely difficult. There are all sorts of situations where it’s nearly impossible to set boundaries like that without risking social repercussions.

There are lots of distress tolerance skills that seem really applicable here, things like breathing exercises, soothing oneself with nice sensory experiences (finding the soft blanket in the room and cuddling it), taking a brief mental vacation until the topic of conversation is over, distracting yourself in some fashion (if there are kids around it’s always a good excuse to say you’re just going to go play with them). It’s hard, and it might require limiting time around people you’re not sure you can trust with your mental and emotional health, but as relationships get closer you can start setting clearer boundaries.

The problem in my mind is that it’s still considered socially unacceptable to discuss your mental health in a casual way. It creates situations like these where there will always be unspoken needs because we’re not allowed to speak of mental illness. While physical illnesses aren’t always treated much better, it isn’t considered totally weird or unacceptable to say “hey, can we not have nuts for dinner since I’m deathly allergic and will have a horrible reaction.” It’s considered healthy, logical, and reasonable, rather than oversharing, being demanding, or straining a relationship. For some reason saying “I have the equivalent of a mental allergy to this conversation, can we please stop talking about it?” is awkward and unacceptable, something that opens you up to questions about whether your problems actually exist, or even can lead others to purposefully trigger you.

This might be one of the smaller areas in which mental illness stigma exists. It’s the little times that you have to bite your tongue and just deal with other people metaphorically standing on your feet by discussing triggering or difficult things. But those little moments add up. Each time they happen you have to have an internal dialogue about what you’ll do and how you’ll cope. It uses up important resources. And it normalizes the idea that you don’t deserve to be able to ask for things, even if others aren’t directly sending that message. The unspoken rules of relationships say that until you know each other well, you act polite.

I’m going to try to make a promise to myself that I will attempt to be better at boundary setting, even in situations like these where it’s possible that it will harm the relationship. I don’t have to be rude, mean, or demanding, but letting people know what is harmful to me can go a long way towards normalizing the idea that it’s completely ok to have needs and wants, as well as openly express those needs and wants. It’s even ok to just say that you have a mental illness and invite no further discussion.

This kind of rock and hard place situation doesn’t have to exist. There is no logical reason that disclosing an emotional need should be inappropriate or unwise. So I am going to change something I don’t like by changing my own behavior.

Last night I was listening to an episode of Radio Lab that focused on nihilism, particularly nihilism as part of pop culture and why the current moment seems to view nihilism as cool in some fashion. A number of the people on the show mentioned that this moment in time is on a pendulum swing towards nihilism. Some moments in history are more despairing (The Great Depression, immediately post WWII), and we seem to be in one of those moments now.

There’s no real way to measure the cultural milieu of any given point in time, but I don’t think these postulates are saying anything too outlandish. A lot of people are feeling frustrated, hopeless, and angry. One of the guests on the podcast was a philosophy professor, and he told the story of teaching a class about mystics in ancient Rome, people who left the city because it was too corrupt, went out into the desert, and practiced an ascetic lifestyle in order to give themselves over to God. They denied their bodies as a way to escape the sense of nihilism.

Today, we’ve tended to use a kind of irony or sense of coolness to bypass the nihilism. Apocalyptic stories abound, dystopias are the new favorite plot device, and yet somehow we’re all a little blase about it: the hipster mentality is still strong in our desire to not appear too worried about everything. We’ll wear the garb of despair and smile while we do so, convincing ourselves and others that it doesn’t really bother us. I think it’s a cop out though: we’re not really facing what it means that we’ll die, that things suck. It’s a cheat code.

So what does this have to do with anything else that I talk about ever? Don’t get me wrong, I’m a pretty serious nihilist, and I love me some depressing philosophy, but there’s a little something more I want to talk about.

Eating disorders. Surprise, I know.

Lots of people have made connections between saints who fasted and eating disorders, questioning whether there is a connection between the two. But asceticism has a long history, and I think ancient mystics can give us some insight into why and perhaps why eating disorders appear to be so common today. One theory of how to move through nihilism (not simply ignore or bypass it) is through an extreme form of love, as the mystics had for their god. They showed how little they cared for this world by dedicating themselves entirely to devotion of god instead.

There’s also simple scientific evidence that ascetic practices like self harm and restriction of food can result in brain chemistry changes that often feel addicting and rewarding. There is clearly some connection between a society wide feeling of nihilism and despair and the choice to repudiate the body. I suspect that many people with eating disorders have the same sorts of feelings. The particulars might be slightly different, especially since selfishness and materialism are often pointed to as the source of the suffering in the current moment (it doesn’t seem a leap to think that the way out of that suffering would then be to utterly repudiate the self).

The impulse to find something more lasting and more meaningful when things feel utterly pointless is a strong one, and it isn’t a new one either. Many people see their bodies as a symbol of their temporal selves, and it can easily become the enemy. Perhaps the current explosion of diagnoses says more about the purposelessness many people are feeling than it does about the media or body image.

I suspect that like wearing your nihilism as a patch of coolness, destroying the body also doesn’t actually help you face the reality of pointlessness. It numbs out the feelings, certainly, it gives the illusion that you’re doing something and moving forward, and perhaps eventually it puts you face to face with death in such a way that you have to face it, but far too often it’s just a way to hide from the things we fear.

I have no idea if there’s evidence for these claims. This is simply drawing connections between things that appear parallel or similar. If anyone has further thoughts, I’d love to hear them as I’m just fleshing out these ideas.

 

No, This Is Not How To Raise Awareness

Ugh. Ugh ugh ugh. Eating disorder coverage has been getting better in the past few years. I’ve seen stories covering orthorexia, binge eating disorder, bulimia, and EDNOS, as well as some that include the oh so shocking fact that eating disorders don’t just happen to people who are skinny, and sometimes they’re not motivated by weight loss, dieting, or models.

So I was deeply unhappy to see this art series that purports to draw attention to eating disorders but is exclusively composed of skeletal Disney figures. Sure, it’s great that it includes men and women of color, but there is such a small percentage of people with eating disorders who actually look like that, whose BMIs have dropped down into the “you need to be hospitalized” realm that I can’t help but feel that it just limits our perception. Beyond that, it perpetuates the horrible, horrible idea that you can diagnose a mental illness by seeing how skinny someone is.

Newsflash: eating disorders are not defined by someone’s weight. Weight is actually one of the smallest components of diagnosis (there are lots of other criteria! And lots of different disorders! Some of which include NO weight component!)

It is not outreach or advocacy to continue to portray eating disorders in stereotyped ways. This is not helpful.

For real information on what eating disorders are and what they’re like, try NEDA, Science of Eating Disorders, or just check out my back log of blogs tagged with “eating disorders”.

Cross Cultural Eating Disorders

It’s commonly held knowledge that eating disorders are a Western phenomenon. They came about because of beauty standards, small models, and photoshopping. They’re on the rise! Panic! It’s an epidemic!

Only this isn’t necessarily supported by a hard look at the data. One of the problems with assessing whether or not eating disorders exist in other cultures is that the diagnostics for the disorders were developed in the US and Western Europe, leading to a focus on the presentations that we tend to see in those places. As an example, one of the diagnostic criteria for anorexia is “Intense fear of gaining weight or becoming fat, even though you’re underweight.” While this is the motivation for many people to refuse food, it is not true of everyone who displays many of the symptoms of anorexia, and may simply have different motivation.

There are a few different sources of data that contradict the idea that eating disorders are culturally bound or that they are caused by Western beauty ideals. We can look at history or we can look to minorities or other countries that may not have been wholly influenced by Western concepts.

Historically, we have strong evidence that people have been choosing to starve themselves for hundreds of years. The book Fasting Saints and Anorexic Girls traces the history of self starvation from the earliest records through to the first recognition of eating disorders as psychiatric conditions. While the book suggests that these are distinct phenomena because in the past few people have practiced self starvation due to a fear of fatness, behaviorally it shows many parallels.

One particular group of individuals that have similar behaviors to modern patients with eating disorders are religious fasters. These tended to be young women who had little control over their lives in many ways and who chose to abstain from food for extreme periods of time in order to be morally better by ignoring their bodies and focusing on their spirits.

The book includes some quotes from people who chose to restrict their food intake in times past, and concerns about morality, space, selfhood, and perfection come up again and again, just as they do in current conversations about eating disorders. Many of the experiences are couched in religious terms, but the underlying fears (“I am not good enough”, “there is something wrong with my body”, “I need to be better”, “I don’t want this life”) could just as easily be pulled from a study of eating disordered patients today.

Individuals throughout history have chosen to abstain from food, often falling into something like depression and priding themselves on their ability to go without for long periods of time. Their motivations have changed as their social milieu has changed, going from religious, to entertainment, to aesthetic. However many of the sentiments that these individuals express ring similar across time and space.

“It’s like I never knew what self-respect was all about until now. The thinner I get, the better I feel . . . I’m proud of my stoic, Spartan existence. It reminds me of the lives of the saints and martyrs I used to read about when I was a child . . . This has become the most important thing I’ve ever done.” This kind of quote could easily be from a religious faster or a modern individual with anorexia.

Over at Science of Eating Disorders, Tetyana posits “Religious and spiritual reasons are not the only factors that could be contributing to AN in non-Western countries (or Western countries before the ‘thin ideal’). Personally, it would seem to be, that anorexics in those times, would just attribute their desire for weight loss to those reasons much like today it is often attributes to a fear of being fat. But, both of those could just be post hoc rationalizations on the part of the sufferer, to make sense of their otherwise perplexing desire to restrict their intake and lose weight. That’s my feeling.”

I’ve written elsewhere about how restricting food made me feel powerful, godly. I often imagined that my body was not subject to the same requirements that others were. Only the weak needed food, but I decided my morality, my meaning, and my body for myself.

“Comparable to the ascetic practices in the history of Christianity are the fasting practices in the Chinese Daoist tradition (Eskildsen, 1998). These practices sought to transform the body as a means of gaining immortality…  The history of Chinese thought thus suggests that, in certain traditions at least, the emaciated body has been highly valued and pursued in a manner highly reminiscent of Western observances.”

But in addition to historical examples, we can also look at current cases of eating disorders in non-Western countries. It’s a common trope that these are rare, and when they do appear they are evidence of growing Western influence in the country. The problem with that assumption is that many individuals who might be diagnosed with an eating disorder but lack fatphobia are not given the diagnosis. The unthinking assertion that the rise of eating disorders correlates to increased Western influence doesn’t look at the lived experiences of individuals in non-Western countries.

Again, from Science of Eating Disorders:

“For example, one study found that in British Asian girls, dietary restraint was correlated with traditional (rather than Western) values (Hill & Bhatti, 1995). This finding was supported in a study by Mumford and colleagues (1991) who essentially found the same correlation. On a Caribbean Island, with little Western media, Hoek et al (1998) found that the prevalence of AN was comparable to Western countries and a study by Apter et al (1994) showed that a group of village Muslim women (with minimal exposure to Western values) had eating pathology scores that were indistinguishable from patients with AN.”

Many of the patients quoted in this article don’t talk about a strong desire for thinness or weight loss, but point to their bodies as the site for other struggles in their lives, particularly around control and selfhood.

“… food restriction arose from a sense of powerlessness in the family context, it is possible that the patient experienced her emaciation as egosyntonic, with her low body weight consonant with the goal of not wanting “to ‘give in’ to her family, especially her mother, who forced her to eat even when she was not in a mood to.”

Again, these individuals exhibit many of the same behaviors as individuals diagnosed with eating disorders in the Western world, but don’t show the obsession with thinness or fatphobia that we assume is an essential part of an eating disorder.

An eating disorder is a coping mechanism that allows an individual to survive extremely difficult situations or feelings. Physically, it has effects that make it easier to live through strong emotions: it numbs out painful things, it leaves you sleepy and sedated, and it also provides a kind of high that makes you feel accomplished and safe. These are biological results. They are the same no matter where you are or when you’re living. And they are effective at helping someone survive a difficult situation no matter what kind of difficult situation that is: it could be not living up to religious expectations or not fitting into a beauty ideal.

And so I am continually dismayed at ridiculous articles like this that seem to think eating disorders are not only limited to the West, but also limited to young, naive, shallow teen girls who can’t figure out how to do basic things like feed themselves. Diagnosis, demographics, and etiology are complex and confusing. If you don’t know a little something about mental health, don’t write about it.

Words: Yes They Do Have An Impact

People suck at talking about mental health issues. Oh sure, there are some people who have taken the time to educate themselves who know not to use “OCD” to mean “neat, tidy, type A”, but the media as a whole is just not good at portraying mental illnesses as real, serious, and illnesses rather than choices. More often than not, writers rely on a few stock phrases to describe mental illnesses. And more often than not, these phrases are misleading, reductive, or flat out wrong. There have been a plethora of examples of a few of these recently, and I’d like to highlight two that are damaging and overused.

The first one caught my eye after an odd kerfluffle involving a pair of Victoria’s Secret models. One commented that she would never have a body quite like the other’s and that she thought the other was beautiful. Not too outlandish of a thing to say: even models have some insecurities and compare themselves to other people. The response? “Accusations of anorexia”. Sorry what? Accusations? This is somewhat akin to saying “accusations of having pneumonia”. Grammatically it sort of makes sense, but in the actual ways that we understand the word “accusation” it implies some weird things about anorexia. Namely that it’s a choice, that it’s something bad or wrong, that it’s something offensive and you should feel ashamed of it.

It’s a phrase that gets bandied about fairly often, as if anorexia were some sort of character flaw that we should all be above. In discussions of “skinny shaming” (a phrase that should have its own post), naturally thin people often comment that they are accused of having eating disorders because of their body type. It makes sense that no one would want to be told they have a mental illness if they don’t. It implies that you need to change or that there’s something wrong with you. More often than not, it’s impossible to convince the world otherwise if they already believe you have a problem. That sucks. Of course it does.

But having someone mistakenly think that you’re ill is not the same as being accused of something, and using that wording does a huge disservice to people who actually do have eating disorders. It tells them that their disorder is something they should feel some amount of shame over, something they shouldn’t be open about because it’s clearly still seen as a choice or a character flaw rather than an actual illness. The phrase often perpetuates the idea that people with eating disorders are all skinny and that you can identify them on sight, because it’s most often leveled at thin people with no other evidence of an eating disorder beyond “you’re really skinny”. Very rarely is someone “accused” of having an eating disorder because they express unhealthy or damaging attitudes towards their body.

Other ways of phrasing this idea might not be quite as succinct. “Believed to have an eating disorder” doesn’t come across in nearly as dramatic a light. But it is more accurate, and that means that it’s preferable. The way we talk about eating disorders contributes greatly to the perception of them and whether or not we see them as serious. This is an extremely easy adjustment to make that can help decrease the stigma around eating disorders.

On the other end of the spectrum we have the endlessly overused phrase “battling depression”. In my Google alert for depression today alone I saw three articles that used this phrase in their title. There are probably times and places to use the word “battling” when describing someone’s relationship with depression. There have definitely been times in my life when I’ve felt as if I’m waging a war inside my own mind. But it should not be the only phrase we can come up with to describe an illness. Especially because depression is not always incredibly active in someone’s life, even if they do still have it, the phrase “battling” can be misleading about what it’s like to live with depression. Sometimes you’re surviving. Sometimes you’re struggling. Sometimes you’re being beaten up by your depression. Sometimes you just have it.

Of course it’s hard to have depression, and most people who have it end up fighting back against it in some fashion or other at some point in their life. But not all of us feel like we can do it all the time. Not all of us have the energy to constantly be “battling”, and the implication that having depression is always a battle means that if you aren’t fighting back then you’ve accepted it and you’re not trying hard enough. While depression has started to move past some of the stereotypes and stigmas that still seriously plague eating disorders, we do tend to have a single narrative about it, and it’s rarely one that recognizes the complexity of what it means to experience depression.

We rarely note the fact that people with depression live like most other people, have hobbies, sometimes enjoy themselves, have relationships, hold down jobs, have good days and bad days, sometimes let the bad feelings happen and sometimes work really hard to feel better, just like most other people. They have an additional stressor to deal with, but they’re more complicated than a single trait.

I’m certainly not proposing a complete ban on the phrase “battling depression” but for goodness sakes could we shake it up every once in a while? This is just getting to the point of extremely bad writing, and we can do better.