Back in 2012, I had been managing my eating disorder for a full decade. Restriction had enslaved me for ten very long years, and I could no longer deny that my body and mind were crumbling, that this mode was not sustainable. As I desperately searched the Internet for an escape hatch, I discovered Gwyneth’s first website. (continue reading below)
I devoured the information there and, with the encouragement offered by this community, I soon dove into the thrilling promise of re-feeding and repairing my body. I expected that my boundless eating and faithful adherence to the now-termed Homeodynamic Recovery Method would ferry me right back to my old body, and my old self, in a matter of months. However, I had to not only accept but embrace a long and jostling journey.
During the perilous two and a half years that comprised my path to remission, I wrote it all down—my ambivalence about my expanding body, my realizations about weight and health, my frustration with the exhaustion and relentless aches in my limbs—as a record for myself and my family and, with much encouragement from those on these forums, as a kind of roadmap for you.
But like my recovery process, I, Dragonfly: A Memoir of Recovery and Flight ended up being much more than I ever imagined, and it required much more time and cultivation than I had planned.
I had originally conceived my story to conclude with my husband and I toasting a decade of marriage under our belts and the end of my era of anorexia. Instead, as I excavated and nurtured the self I left behind at age twenty-three, I discovered that the dynamic between him and me no longer seemed to fit with who I was becoming; it was like a dissonant chord in a symphony of self-actualization. The resulting unraveling of my marriage was devastating and the worst casualty of my recovery process—and thus something I had to write about.
As I’ve read on these forums and heard from others in recovery, many of us find our reclaimed selves now disconnected from aspects of our lives that had once felt vital and permanent. Sometimes this recognition results in a welcomed shift, such as the healing or strengthening of relationships with family or friends; sometimes this can demolish your life as you knew it, as you perhaps you force yourself out of a physically demanding career or, as in my case, choose to divorce your partner in life and parenting. I had to take the time to integrate these really difficult things. I had to learn how to write about the messy things that intimately involve others, in order for my book to offer a fully fleshed view of what recovery can entail.
In the following excerpt from I, Dragonfly, I share the immediate aftermath of my husband and I deciding to separate in the midst of the strains of recovery:
I moved through that day slowly, meandering through wreckage. At least it’s over. After dinner I went up to our bedroom, noting that soon it would be simply my bedroom. I pulled out the same bleach-spattered sweatpants that I’d been wearing as pajamas since October because I couldn’t bear to enter a dressing room and watch my body not fit in a size I could swallow. A little fist knocked low on the door. “Mommy, can I come in?” sang Eliza’s distinctly melodious voice.
“Sweetie, I’m getting dressed. I’ll come right out as soon as I’m finished.”
“But Mommy, I want to see you! Let me in!” I could hear her tiny three-year-old body slump to the floor, the sobs. This time I couldn’t tell her to go downstairs and see Daddy instead. They had to know how much they were loved, before their world would be thrown into confusion.
Eliza climbed onto the bed and watched. As I stripped off my leggings and a shirt losing its hem, I answered once again that the thing around my chest was a bra. I braced myself for one of those maddeningly sincere toddler comments like, “Mommy, your butt is big!” which I’d already heard at least once in the past month. Please don’t say anything. I can’t take it today. I turned away from her as I dressed, and not until I had the shirt completely over the belly I loathed—the extra fat that my body was still hoarding around my vital organs in case of another bout of starvation; the extra me that lipped over the C-section scar—did I spin to face her, expecting her to be focused on pulling at a loose thread in the duvet, she had been so quiet.
Her eyes, her cheeks, her wide smile framed by the rounded lips she inherited from me—all of her—were beaming at me as she remained seated at attention, hands in her lap. “Mommy, you look beautiful.” And she smiled some more. I grasped her soft upper arms, and tears rolled down my face. She kept smiling.
At first I cried because someone could think I was pretty even in that swollen body topped by a sleepless face. Then I cried for my daughter’s innate capacity to recognize beauty purely—not as a certain combination of straight and curved planes on a body, but as any shape illuminated from within, lighted by the soul fire that I had been stoking through my recovery. Cradling her head and smoothing her fine hair I wished for her a lifelong path toward such higher meaning, never to be shot down by the societal pressure to be anything that isn’t authentically Eliza, and absolutely never to be shackled by an eating disorder. And the only way for her and her siblings to fly like that was for me to continue my own course, to accept destiny, to go wherever recovery was taking me, even if that entailed the end of my marriage, their family as they knew it. I had to lead, and to be the example.
Those four words from a three-year-old—Mommy, you look beautiful—reconciled the terrible doubt that I was choosing myself over them. I was, in fact, choosing all of us.
In my story, the choice to honor physical hunger was merely the first step. For me, recovery unveiled all the further choices that had to be made, and it demonstrated that the process required healing and inhabiting every corner of myself. It taught me to be open to my own transformations; it challenged me to listen to the universe as I continued to evolve. And that is why I chose I, Dragonfly: A Memoir of Recovery and Flight as the final title for my book—because although the story is anchored in the swamp of the recovery process, it is a tale of becoming, and of flying forth.
I feel both proud and humbled to have sustained a state of remission for longer than three years and to share with you this memoir of my process, to give back to the community to whom I owe my life. While every recovery journey is different, I hope that you find camaraderie, encouragement, and solace in this chronicle of my own path. And ultimately, I hope that you, too, discover the profound and enduring contentment of honoring the needs of your body and soul every day.
I, Dragonfly: A Memoir of Recovery and Flight, which includes a foreword by Gwyneth Olwyn, will release in e-book and paperback editions through international online retailers Amazon, Barnes & Noble, iBooks, Kobo, and others on March 13, 2018.
All proceeds from preorders placed from February 26 through March 4—in conjunction with the US and UK National Eating Disorders Awareness Weeks—will be donated to F.E.A.S.T. (Families Empowered and Supporting Treatment of Eating Disorders), an international organization promoting awareness, support, evidence-based treatment, and research and education advocacy around eating disorders.
Kerrie Baldwin is an editor and writer with twenty years’ experience in children’s and adult trade book publishing. Her interest in the science behind eating disorders is fueled by her additional work as a medical editor in the pharmaceutical industry. She lives with her family in the Catskill Mountains of upstate New York, and she can be followed on Twitter at @kerrie_baldwin.
I often get asked this question from those embarking on applying the Homeodynamic Recovery Method (HDRM). Presumably it gets asked because we’ve designed the entire eating disorder treatment system as a get-in/get-out medical stabilization process and surrogates for “recovered” status are limited to a body weight and acceptable biomarker readings (resting heart rate, blood work and the like). If everything you’ve experienced to date has framed your process of recovery as something you do rather than something you are, it’s understandable you ask: “When will I be done?”
HDRM is not a doing thing, it’s a being thing. It’s more like learning a new language— or to be more specific, like re-learning a profoundly lost language. It gets easier as the years go by to be fluent and to even think in that language, but if you’re tired, stressed, or faced with vocabulary that’s specific to a particular profession, it’s easy to slip.
I know it’s really difficult to pry yourself away from using your weight being the definitive marker of your health status, but the longer you cling to that cultural fallacy (and that’s all it is), then the longer you live in a half-life of being beholden to false fears.
Staying completely energy balanced is the mother tongue of everyone around you who has never experienced an eating disorder first-hand. And we live in this weird world where all those natural speakers pretend that they actually speak the language of restriction.
They talk about their diets, their exercise regimes, their eating healthy, their getting back in shape...as though they really do manage to create energy deficits the way you do. So anxious and panicked are you (which is the eating disorder jammed into your threat identification system), you often fail to notice how those around you, in the world without eating disorders, actually make no sense at all.
How English sounds to non-English speakers - YouTube
If you’ve never had a chance to see the video above, it’s a really well-constructed piece on what English sounds like to non-English speakers. If you weren’t really paying attention, you’d think (given the inflection and pace) that they are speaking English.
That is the world of so-called healthy living— just gibberish masquerading as real language. All those around you without eating disorders actually thrive in their mother tongue of energy balance and it’s purely an action-based language. All the while, they speak gibberish at each other about their status-signaling healthy living.
Embracing HDRM for your recovery process is about ignoring the gibberish around you and developing a reconnection with your own mother tongue of energy balance. Those without eating disorders cannot sever ties with that energy balance; but for you it has likely become a completely foreign language where you don’t even recognize the basic words anymore, let alone are you able to construct a complete sentence.
It feels awkward, unnatural, severely anxiety-inducing and generates constant second-guessing:
— “Am I doing this right?” —
It does get easier as the years go by. You will get to be an absolute expert in picking up on the gibberish around you: “That’s not English,” or more to the point, “That’s not Energy Balance.” You won’t have to concentrate so hard to be fluent in Energy Balance.
But the restriction gibberish will always sound a bit more familiar to you, especially in times of stress or distraction.
I get criticized for speaking in terms of “never being recovered from an eating disorder,” on the grounds that it denies individuals their own agency and that no third party has the right to override an individual’s own definition of being recovered.
I absolutely agree with people’s rights to define their own state of health. But I am wary of anyone touting their “cure” to others as I believe that the rights of those convinced of that cure are as, if not more important than the individual’s right to self-identify as “cured,” or “recovered.”
All that is to say, having peer mentorship during your remission practice is invaluable but do consider clinging a bit more tightly to those who treat an eating disorder as the chronic condition that it is. No one is ever done with practicing remission.
And just as it’s really tough to learn a new language when everyone around you is still speaking the old one— they want to practice their gibberish on you as you’re such a native speaker of restriction— consider carefully what environments and people support your efforts to be fluent in Energy Balance and then work to be surrounded by those things and people as much as possible.
This post has a bit more of me in it than is usual, but I think my own experience may be of value to others who regularly read posts at the Eating Disorder Institute.
Jam Zhang: Flickr.com
I’ve often reinforced the fact that genes are not destiny, and that’s because it’s the truth. There’s an entire lineage on my maternal side with the genes that are linked to celiac disease but few of us have the condition. Genes are like literary tools in a mystery book: they might suggest foreshadowing, but then again it could be the reader is going to be thrown entirely off track by their presence, or perhaps they only had relevance to a subplot and not the main plot, and finally it might just be they served no purpose but to entertain.
But just as the arctic tundra is distinct from the alpine tundra is distinct the boreal forest, our own human living ecosystems thrive within a range and are brittle and resilient in their own distinct ways. And it is the relationship of our genes with our environments that shape the ways in which we might become brittle and the ways in which we might become resilient.
When I was a teen, I had orthodontic braces. It was done somewhat later than my peers because I had a traumatized tooth (from a fall as a kid) and the orthodontist was waiting to see whether the root would die or not (it did) before placing the braces. Unbeknownst to me, it appears I was someone who was predisposed alveolar bone loss when applying those kinds of forces on my teeth to straighten them. That, combined with a marked tendency to clench down hard on my teeth while sleeping and post-infection inflammatory responses that seem to be worsening with age, and my gums are now in a sorry state and I risk losing my teeth or having major dental surgery and bone grafts to attempt to save the teeth. I’m not there yet.
But at my latest dental hygiene appointment, it was made clear that things are trending poorly. I was really upset for a few days. I felt betrayed. I have always had impeccable dental hygiene. Because I am very difficult to freeze, the excruciating nerve pain that often accompanies fillings for me has been a great motivator for being absolutely rigorous about preventative treatment. I religiously have my teeth professionally cleaned on time, I floss and brush twice daily and I wear a night guard on my teeth every single night to try to minimize the damage of clenching as well.
After feeling my body had betrayed me then, as is my tendency, I felt fatalistic and wallowed in some good old-fashioned catastrophizing. Basically, I felt sorry for myself: “Of course, I will lose my teeth and be a frightening sight to little kids. I have all these chronic conditions with inexorable worsening inflammation and pain. I will age horribly, suffer and die alone.” Then of course I heaped on all the cultural moral implications our society places on how individuals look and the assumption of what a lack of teeth represents: “You didn’t take care of yourself, you had poor hygiene (ewww!), you were irresponsible, lazy and worthy of other people’s disgust.”
And finally, as I completed my process of assimilating the reality, I felt grateful and accepting. It’s possible I will lose my teeth. Everything that I, and my dental team, can do is being done to perhaps prevent that or at the very least delay it. But I haven’t lost them today and I feel very grateful for that. I cannot prepare in advance for what needs to be done should they fall out in any case. Worrying and being anxious for that day gets me nothing except worry and anxiety. As for my culture, well I’m not much of a fan of it in any case, so I’m capable of keeping its moralizing garbage out of my own headspace and heart.
There are of course a lot of “what if’s” I could perseverate on to keep me locked in fatalism and resentment. I could blame my parents for not forcing me to stop sucking my thumb as a child which may have avoided the need for braces. Or conversely, my parents could have persuaded me not to have braces later on. Or perhaps I could just have somehow avoided all the night-time clenching that started alongside full-time employment as an adult. But hindsight bias is such a misleading space to squat in. You change one thing about your past and what else changes with it? We don’t know because we experience time in a narrow linear construct where we also naïvely assume that we could keep all the good and magically excise the bad along that line from then to now. Even excising the bad of the past might have the unfortunate outcome of rendering you less resilient in the now in ways you could not possibly predict.
And there was one additional observation I made: I would know nothing of this possible future state had my dentist and hygienist not recently attended a conference wherein recommendations were made for specific x-rays to determine alveolar bone density. I gave my consent for those x-rays and yet had I not, then I would have been spared a lot of emotional processing of a likely future state for which there is nothing that can be done that is not already being done.
And all this navel gazing brings me to the countless patients in recovery from eating disorders I’ve interacted with over the years. Some blame me for how their recovery processes went completely pear shaped (figuratively if not literally). Many more blame themselves for a recovery process that doesn’t seem to progress in the so-called right way, or worse just seems to go from one extreme crisis to the next.
I would never suggest that something as objectively irrelevant as losing your teeth is actually equivalent to some of the serious medical, emotional, financial and life changing crises that can occur for many during recovery from an eating disorder. But I can suggest that no matter the crisis, getting stuck in the damage of feeling betrayed, fatalistic and resentful adds insult to injury.
My experience is also a firsthand example of submitting to screening tests for which I did not assess whether I wanted to know and what, if anything, knowing would remediate should the results be less than ideal, before agreeing to the test (in this case checking alveolar bone density). Yes, this is yet another bias of mine that you can take or leave, but I have gained nothing by consenting to those x-rays except the need to process a whole bunch of anxiety and worry. Everything that can be done to save my teeth was already being done with regular excellent dental care, so the trajectory of treatment is no different before and after the x-rays.
So, if there is any what-if that I do take away from the experience it is that I must work harder to apply my prerogative for my own health outcomes by choosing not to know when that suits me best. I know that my medical mind is one that has no interest in pretending something is in my locus of control when it isn’t. If you don’t happen to know yet what your medical mind prefers, then I would recommend you get a hold of Your Medical Mind: How to Know What Is Right for You.
There are no assurances in life and in recovery. You can do everything and it’s not enough because it’s not all yours to control in any case. Just because all the excellent dental care in the world may not assure me a lifetime with my own teeth doesn’t mean that I would ever have been better off without that care. And hopefully no matter where your recovery effort might lead you, you will still know that a life in the grips of an eating disorder will never have been the “better off” scenario for you.
I am unloading a series of blog posts this week on neutralizing fattism and healthism at seasonal gatherings, although hopefully these concepts can apply year round. As a refresher, fattism and healthism pertains to diet talk, the healthy-living behaviors talk, the body shaming and the good/sinful dichotomy of food that ruins what might otherwise be cherished time with those closest to you. Part I, II and III in this series can be found here, here and here.
Marceline Smith and Virginia State Park: Flickr.com
This is the last in the series Happy NO-lidays. In Part I, we covered off off making a self-protective decision not to attend seasonal gatherings at all when you are navigating recovery from an eating disorder. We then investigated finding ways to create a fattism- and healthism-free zone at a holiday gathering in Part II. Part III looked at the problem of fellow-anxious relatives and friends who will not be able to adhere to a fattism- and healthism-free zone, and how to shut down the infectiousness of that kind of anticipatory threat reaction.
Recently on the forums we had a thread where a member expressed frustration at having been lulled into an “I’m cured” relapse. As I mentioned at the time, the “I’m cured,” thoughts plague those in remission from all kinds of conditions: asthma, rheumatoid arthritis, lupus, diabetes (both types)...and for almost all the decision to stop taking medication, or throw lifestyle constraints out the window (getting enough sleep, etc.) leads to relapse.
But returning to remission from a relapse of any chronic condition requires recognizing that a latent condition is not the same as one that doesn’t exist at all. Your health and longevity depend upon always making certain conscious decisions, choices and actions every single day to ensure the condition stays in remission.
The desire to wave a magic wand, or enact a spell or ritual that will mean “Poof! No more eating disorder,” is strong because social norms dictate that engaging in pastimes of fattism and healthism mean you belong—you are not separate, other, or without status in your culture. In fact, another member on that same thread stated how badly she wished she had magical powers.
This final installment in the Happy NO-lidays series hinges on the possibility that those in recovery already have a magical power; they just have to figure out how to wield it. As I responded on that thread:
“I think it might be a magical power to be able to identify when the culture you have been surrounded by and absorbed through osmosis since birth is full of false ideas, rules and arbitrary morality that can harm you and others.”
Although the Homeodynamic Recovery Method logo appears with either a light green outline or black outline, he is truly the quintessential white rabbit.
The rabbit represents an invitation to explore the truth all while coming to terms with its elusive nature—just as Alice follows the white rabbit in Alice’s Adventures in Wonderland.
For most adults with eating disorders, remission has the odds stacked against it. Our approach to eating today is steeped in fear mongering and moralizing to such a degree that those with eating disorders get no respite from the unrelenting anxiety that any given food choice or activity might be wrong. Therefore, remission is found underground: down the rabbit hole.
Once you’ve stepped into the rabbit hole of a recovery effort, you will return above ground to live in remission, but you also face the same culture you left behind. You cannot un-see its failures and limitations. Adjusting to your new magical power of seeing those limitations and failures takes some time.
Initially, you might want to open everyone’s eyes to both the unscientific absurdity and cruelty of fattism and healthism. Then you may find yourself filled with righteous anger at the general disinterest there seems to be towards any change. Not only that, but you find many people seem to zealously and angrily protect their dogmatic belief system. From there you may withdraw and experience sadness.
Eventually, you find that personal space that will allow for you to live your belief system as a way to embody a fattism- and healthism-free space. It is a space of empathy and self-compassion.
Empathy is the ability to share and understand the feelings of someone else. It’s not pity and it’s not mirroring either. Pity involves distinguishing the other person’s feelings as inferior in some way—unenlightened. Mirroring is what I discussed in Part III of this series—where you identify to such a degree with the other person’s feelings that you fail to distinguish the separateness of your own emotional timbre from what the other person is experiencing.
As you witness the very dominant buzz around you of fattist and healthist anxieties, you can empathize with these tortured souls who are your friends and family this holiday season. You’ve been there and you are no longer there. Empathy.
Maybe rare and tireless masters truly have boundless levels of empathy to spare, but if you’re anything like me, eventually the mouth muscles start to hurt from so much beatific smiling and then you are so done. That’s when you have to head on over to your self-compassion toolbox instead. You can visit self-compassion.org for ideas.
Having any magical power means you still have to figure out how to use it; when to use it; and, most critically, when not to use it. And that takes us back to the first installment in this series: it’s okay not to go to these celebrations and it’s more than okay to duck out early, make a token appearance, or otherwise limit your exposure to fattism and healthism. Magical powers take years to master.
I am unloading a series of short blog posts this week on neutralizing fattism and healthism at seasonal gatherings, although hopefully these concepts can apply year round. As a refresher, fattism and healthism pertains to diet talk, the healthy-living behaviors talk, the body shaming and the good/sinful dichotomy of food that ruins what might otherwise be cherished time with those closest to you. Part I in this series can be found here.
Marceline Smith and Virginia State Park: Flickr.com
Now we’ll talk about those of you feeling a level of returning resilience that has you thinking you can commit to being present at the get-togethers this holiday season. If anything will grind down your newfound resilience it will be the almost non-stop fattism and healthism coming from your loved ones.
One of the advantages of having to navigate getting to remission from an eating disorder is the ability to see cultural norms from a distanced vantage point. How many people who don’t have eating disorders really know how damaging it is to not only restrict food intake and exercise, but also to beat oneself and others up with the destructive body shaming and negative self-talk?
Ahead of the celebration, you can send out an e-mail to all those attending to offer up the recommendation that this year’s celebration will be a fattist and healthist-free zone. This is the “we’re on each other’s team” approach. It won’t likely work if you have others attending with active and untreated anxiety or eating disorders. I’ll get to that scenario in Part III of this series tomorrow.
It’s probably a good idea to go into some detail in the e-mail. Give some facts and talk about how a group that conscientiously removes status and judgment from a celebration will get to enjoy a more fulfilling and nourishing environment.
Fast facts you might offer up in the e-mail:
Food intake and exercise do not link to overweight or obesity onset or perseveration. Reference the actual systematic review literature that I provide in the blog posts: here and here.
Diets fail (spectacularly). 99.997% will regain more than 77% of the initial weight lost five years out.
New Year’s resolutions are successful approximately 8% of the time.
Eating sugar, saturated fats, ultra-processed foods, butter, cream, trans fatty acids etc. don’t cause disease or chronic conditions. All the studies you read about foods and disease only show linkages and the linkages are grossly over simplified to make it look as though increased risk is self-evident: e.g. sugary diets increase the risk of diabetes. It could actually be that diabetes increases the risk of sugary diets; or some unknown factor or factors not being studied actually play the causative role in diabetes onset. No one knows.*
Bad things happen to good people. Stop torturing yourself with the ridiculous presumption that diet and exercise fix everything. Not everything is in our control, but we have each other so let’s enjoy this season together.
You can make a game of it if the folks attending tend to like that kind of thing. Each person gets tokens (different color for each person). Every time someone slips up and starts talking about diets, making a negative comment about their body (or someone else’s body), talking about being good or bad with their food choices, or complimenting weight loss and thinness too, then they are charged one of their tokens and it goes in a jar. At the end of the visit, you could choose to either charge the person with the most tokens in that jar with the responsibility of hosting the next celebration, or you can make a token equal to a specific sum of money and everyone has to put the money they owe into the jar at the end of the visit. Perhaps you then give that money to an agreed upon charity.
You can also offer up topics of conversation that will be welcome instead of the usual fattist/healthist banter:
What was the most exciting thing you did this past year?
If you were independently wealthy, what would you try to accomplish?
What was the most interesting or engaging conversation you’ve had recently?
What hobby do you think you should either pick up again or try for the first time and why?
If you could invite any person living or dead over for dinner, who would it be and why?
Is there someone in this room today you want to thank for something yet you never seem to get around to doing it? (no time like the present!)
What do you think is the best part of being a member of this family?
When was the last time you laughed until you had tears streaming down your face and couldn’t breathe?
What’s the most surprising or interesting thing you’ve learned recently?
What country do you want to visit (if money were no object) and why?
Obviously your own creative questions will make it that much more appropriate with your family and friends.
Next installment coming tomorrow....
* You’ll find all the peer-reviewed published references on this topic in the blog posts under the category Obesity Basic Facts found here.
That seems like a fitting title for what I want to discuss today. More important things are happening in the world now. Discussing eating disorders at all seems elitist, superficial and ultimately discordant to many at the moment.
Sophie Charlotte: Flickr.com
Nonetheless, there’s an important reason in my mind why eating disorders matter more now and not less. And no, it’s not actually because Trump is president; it’s because we live on a finite planet of dwindling resources with too many of us here (and aging) at one time. We are sliding into a bickering rating system for how much more important various social injustices are in comparison to each other.
The Women’s March of Saturday January 21st was about as broad and unifying an effort to counter the fight to stay on any particular rung on the social justice ladder as we’ve seen lately. And even then, transgendered, indigenous and black women correctly pointed out that the march side-stepped the inconvenient truth that, of the women who even voted in the US election, 53% of white women voted for Trump (not to mention many transgendered, indigenous and black women felt decidedly unwelcome at the march itself as well).
We will struggle to unite much of anything in the months and years to come. If I were to use another analogy (musical chairs rather than rungs on a ladder) then the time to unite was when there were still enough chairs in the game that everyone could have a seat. If you are already on the sidelines, having been left standing when the music stopped at some point in the distant or more recent past, then it’s understandable you are not really vested in cheering on those still circling the dwindling chairs.
We are mammals. Mammals have a predictable set of responses to overpopulation and dwindling resources and primates in particular have a long evolutionary history of getting downright evil in those circumstances. And we habitually identify the evil in others, always failing to identify that allowing an unexamined fight/flight/freeze threat response in ourselves precipitates the evil within us, and not just in others.
All that pretty much confirms that eating disorders don’t matter at all, right? But they do matter. Yes, we are mammals and, worse yet, primates. But primates can also look after each other. They can protect the weak, the injured or (in our civilized case) those with no chair to sit on. And they do all that by being both afraid and thinking at the same time.
An eating disorder is an anxiety disorder. Having that twitchy threat response system in the brain is not exclusively a drawback in life, assuming you can navigate it rather than it navigating you. Someone with an eating disorder in remission (or being actively managed too) is someone who can apply their anxiety-prone nervous system for good. And we need good in the world.
There are plenty of people naturally predisposed to having a resilient response to setbacks that occur in their lives. I don’t know whether natural resilience is more or less robust than one that is developed through practice, but I do know that getting an anxiety disorder to work for you, rather than against you, makes you resilient.
Therefore, if an eating disorder is standing between today’s you and the resilient you who might navigate whatever the future holds and help those who might need a hand, then nothing matters more than an eating disorder. Or, more specifically, nothing matters more than an eating disorder standing between you and your ability to both be and do something good in the world.
If there is anyone who truly knows how to examine the fight/flight/freeze response and refuse to behave in mindless reaction to it, it’s someone who has navigated a recovery effort from an eating disorder.
Well, of course no one is ever really ready to recover. No one willingly wades into a swamp full of crocodiles and that’s pretty much how recovery feels to the threat response system in the brain of someone with an active eating disorder. Nonetheless there are a few things you can do to have the right croc-management tools with you before you head in.
Fritz Ahlefeldt-Laurvig: Flickr.com
First of all, it bears endless repeating: a starved brain is a profoundly malfunctioning organ. I have already spoken of this under the subheading Sensing Impairment in the blog post: Pro-ana and Pro-mia Sites: What’s the Deal?. The brain has no way to identify its own impairment. So you must take it absolutely on faith that if you are restricting food intake severely and/or creating severe energy deficits through excessive exercise or other compensatory behaviors, then you have to re-feed first and foremost. If those around you are worried you seem out-of-it and unable to grasp the dangerousness of your current circumstance, then much as you are convinced you are fine, you have to accept you are not. Just as you would not drive home after a couple of drinks even though you “feel fine,” you have to undergo necessary structured treatment with medical help if those around you are telling you things are bad.
Heading into inpatient is about medical stabilization as well as upping the intake enough that your brain can manage to function a bit better. Recovery to full remission from an eating disorder actually begins once you are discharged from an inpatient setting.
Plenty of you have gone into inpatient; hit that target weight; been discharged; half-heartedly attended the odd outpatient appointment; and then promptly relapsed.
So here are some options for letting go of that cycle and dependency on “target weight,” and embarking on getting the condition into full remission. There is a three-legged stool concept I use where each “leg” of the stool is critical for getting to remission: re-feeding, resting and brain re-training (psychoeducational support). The minute you are discharged from an inpatient setting (or you are already confirmed to be medically stable to begin re-feeding), then you eat the minimum (usually more) intake guidelines for your age, height and sex that those without eating disorders eat on average every day (see this blog post for details: Homeodynamic Recovery Method, Doubly-Labeled Method Water Trials and Temperament-Based Treatment). You cease all discretionary activities (see here for details: Juggling Recovery and Financial Commitments as well as Exercise I, II and III). And you need to attend to that brain re-training to be ready to continue the recovery process day in and day out from that point forward.
There are two psychotherapeutic tools that are evidence-based for addressing ambivalence and fear: MI and ERP (motivational interviewing and exposure and response prevention, respectively). I have discussed ERP in this blog post: Weighing Yourself: Don’t Do It, so you can revisit that post if you want a refresher on ERP. Let’s look MI.
Drs. William Miller and Stephen Rollnick developed MI originally to help those looking to overcome problem drinking. It is now an evidence-based treatment for those with substance use isues. Dr. Janet Treasure, a leading clinician/researcher in the field of anorexia nervosa, in her thorough article on MI, pointed out its value in application for any situation where there might be resistance to change; however she correctly adds that a patient rarely maintains a stable state of motivation, and therefore this manualized approach to helping a patient adopt new behaviors still requires an empathetic and sensitive therapist who can move back and forth along with the patient as she approaches and retreats from new behavior in nonlinear fashion. 1
The essence of MI is to help a patient explore any ambivalence she may have toward replacing maladaptive coping mechanisms with adaptive and healthier behaviors. Patients will frequently ask me “Can I eat normally and stay the same?” and I refer to these kinds of questions as bargaining with the eating disorder. Questions such as these really reveal the fact that the patient is dealing with ambivalence. If you are feeling stuck, or have found that the anticipated tomorrow of starting to change behavior just never seems to arrive, then seeking a counselor with suitable MI training is a good first step.
If you either cycle through relapses or never quite get beyond tentative efforts at full-fledged recovery, you are not just being held back by the threat response firing up as you try to approach and eat food. You are also held back by the fact that the arc of restrictive eating means that at one point you practiced food avoidance and reinforced it because it generated positive things for you. It may have allowed for you to stop being focused on distressful emotions or interactions in your life; it perhaps provided you with a sense of purpose, control and mastery; and/or it generated improvements in mood and calmness, and made it easier to navigate your world and relationships. Those are just a few of the myriad environmental circumstances that may lead to a reinforcement of restriction once the drive to create energy deficits in the body is activated.
An eating disorder is not a genetic disease. There does appear to be a genetic component for activating a drive to create energy deficits in the body; but the reinforcement and perseveration of those behaviors involves the plethora of anthro-psycho-neuro-immuno-endocrinology inputs (APNIE)—translated this terminology refers to the sociocultural, familial, environmental, psychological, neural, immune and endocrine circumstances and status surrounding and within the patient. APNIE inputs will be unique for each patient.
As restriction is not tenable for life, the modulating benefits of practicing restriction start to recede as the damage and negative impacts of energy deficits in the body start to mount. There is usually a moment where the person in the grips of that downward spiral will try to eat, or the body will force her to eat.
In almost all circumstances, that effort (or force) to stop restricting tends to create absolute chaos. All of the emotions, the difficult interactions with others and the inner mental landscape that were filtered through the deadening power of starvation come roaring back. And on top of that, the misidentification of food as threat (the underlying "engine" of restrictive behaviors even if you don't experience that force consciously at all) means that approaching and eating food ratchets up intense and destabilizing levels of panic. For those that attempt to eat normally again, this will be enough to send them back to restriction, disheartened and feeling more helpless and trapped than before. Those who were forced to eat by the body's drive to survive will return to restriction for the same reasons, and inevitably end up in cycles of restriction/reactive eating and eventually bulimic behaviors will surface.
To be trapped enacting behaviors that you no longer want to apply generates what is called ego dystonia. I describe it this way in Part V UCSD EDC Review:
As an example, if I have a self-conception that I am not someone who willfully kills living creatures, then my propensity to use a glass and piece of paper to rescue and free spiders, wasps, or other insects that have entered my home aligns with that self-conception. If I accidentally step on an insect in my home, then I will experience ego dystonia— I have behaved in a way I find repugnant in relation to my self-conception. I will likely reduce that cognitive dissonance by rationalizing that it was an accident and perhaps might redouble my efforts to be careful to avoid an accidental insect death by my hands (or feet) in future.
If however, I develop a fear of insects, then I might squash the critters as soon as I happen upon them and I will attempt to deal with the ego dystonic reaction with more intense behaviors of avoidance along with more elaborate rationalizations and excuses for not aligning with my self-conception.
Fear is a ruthless taskmaster if it gets a foothold in your sense of self.
You are not just dealing with the feels-real-but-isn't misidentification of food as a threat; you are also dealing with ambivalence created by ego dystonia where you still hope to experience the benefits of restriction without the progressive damage of using those behaviors to cope with your life.
To be ready to continue towards complete remission of an eating disorder, you will need to grab psychoeducational tools such as MI and ERP if you want to neutralize the crocodiles and keep moving forward.
“He made me sit and listen to him for hours and hours while he was going on about how unattractive he thought fat was, how he could barely stand the loss of my skinny body, how he thought I had tricked him into believing I could be thin. He made constant remarks about my weight, my intake and my lack of exercise, made me look at pictures of myself as underweight so I could see for myself how beautiful I looked.”
Deviant Art: alicexz
The above quote is from someone navigating her recovery process from an eating disorder. What follows is an edited version of the response I provided on the discussion thread where this quote originated:
Chattel comes to mind: an item of property other than real estate.
If the person you love is an item of property and not a living being in your framework, then that item cannot deteriorate, break or lose its cash value without it needing to be discarded and likely replaced.
We are complicit if we refer to this denigration of ourselves as “he loves me, but..,” or “she loves me, but…”
Most assuredly chronic illnesses are tough on relationships. And we can certainly say that an internalized loathing of fat can create levels of insecurity in patients undertaking recovery, such that their partners may find the constant need of reassurance somewhat exhausting and emotionally draining. Not to mention that the long periods of swelling, pain and exhaustion during recovery mean it’s hard for recovering patients to be full-fledged partners for quite some time as well. But that does not make them chattel.
Ragen Chastain posted this blog entry: Online dating in a fat suit in response to an original story on Huffington Post where both men and women went on dates set up through an online dating service where they were, in person, much larger than their online photographs suggested. A definite double standard showed up where the men really had little issue with being much larger in person when it came to the date itself, whereas the women were pretty much shunned and outright abused.
Ragen observed: “One man compared it to being a “breach of contract” which I think is pretty telling – the idea that how women look is a contract for services that they should not breach and that a reasonable response to the breach of that contract is a complete suspension of basic human decency.”
Services rendered and breach of contract: “Remain as an unchanging thing that I own and you shall have my love and devotion.”
If you have inadvertently ended up with a partner who believes your looks are a contract you must uphold, then it is wise to assume that the contract is not just about fatness. It will also be about aging, disability, illness, vulnerability and dependency.
Divorced or separated chronically ill and disabled adults comprise 20.7% vs. 13.1% for those without disabilities. 1,2 The interpretation of these survey data suggests a lifetime 75% divorce rate for those with chronic illnesses compared to 50% for the population at large. The reality is that most of us can say “in sickness and health” in the abstract, but when the rubber hits the road it’s a whole different story.
But here’s the thing: you are the one doing all the work to get a chronic illness into complete remission. And if those nearest and dearest are not for that, then they are, by definition, against it. And chances are really quite good that they would not be there for you when the progression of that chronic illness starts to really impact your quality of life and generates progressive disabilities— which is the known trajectory for an active eating disorder over time.
They want the thin and emotionally acquiescent person, but not the progression of sexual organ atrophy, bones too brittle for sex, papery-dull skin, straw hair, broken nails, nor the financial dependence that disability involves either.
The ski-boot analogy (that I use often) works well here too:
When you are at the top of the mountain trying on the rental boots, if you ignore the slight pinching of one boot and head down that mountain, then you can be sure you’ll be halfway down with a blood-blisteringly painful foot.
Partners who believe your shape, looks, weight, or physical attributes are extensions of their status are going to fail you horribly halfway down that mountain. And importantly, it is indicative of boundary issues that go beyond your need to keep your eating disorder active for them.
By all means, if your partner is willing, then seek couples therapy to determine whether appropriate boundaries on both sides might be attainable. But in the absence of any recognition on their part that they would like to be able to salvage the relationship (when you make it clear you will not comply with their requirement that you remain thin) then that leaves you both pretending that the demilitarized zone between you enables you to stay a couple in some sense.
All those with an eating disorder, whether they pursue remission or not, deserve more than a chattel-based primary relationship— especially when that’s not likely to have been the understanding you had of the relationship at its outset. If you did knowingly sign up for being chattel, it’s also more than okay to change your mind; extract yourself from a contract that has outstayed its welcome; and move on.
And if you are navigating recovery and you don’t have a partner who is in absolute awe of your efforts to reach remission from such a deadly chronic condition, then he (or she) just isn’t welcome in your forever home. And I’m not saying you won’t have things you likely need to work on, on your side of the relationship, but being proud of our partner’s achievements and respectful of their struggles is love for a living being and not love of an item of property.
The services provided on this site are five years old as of October 31, 2016. There have been two name changes and three distinct online identities in that time frame as I have developed my own patient advocacy practice within the eating disorder treatment space. Each shift reflects, hopefully, improvements in our service offering and our ability to provide well-researched and conflict-of-interest-free information on how adults with eating disorders might navigate the condition into complete remission.
Nick Lee: Flickr.com
This latest change from Your Eatopia to The Eating Disorder Institute marks the biggest shift we have made so far, but one that I hope reflects the true breadth and depth of information we have synthesized over the years here in this online space.
Each change brings that familiar combination of excitement and trepidation for me, and likely for all of you who have come here over the years for information and support. This rework has been underway for the past six months and has necessarily involved my retreat from more frequent posts and updates on the former site as well. Thank you to our community for your patience over this past half year as you have waited for the changes to unfold.
We have become more well known within existing research and treatment spaces around the world and many now refer their patients to our site. And for those of you who stumbled upon this site perhaps many months or even years ago, you have provided feedback to confirm that the material was difficult to navigate at times and full references needed to be readily available for each post. We have addressed the gaps we felt were present in our former site and hopefully we have succeeded in generating all the improvements you have told us you wanted to see and more.
For an explanation of the new Eating Disorder Institute logo, please visit the EDI Logo under About in our menu bar.
Navigation and Forums
It may take some time for those of you familiar with the old site to navigate around the new categories and features of this site. The “SEARCH” function in the upper right hand corner is likely the best way to find what you might need— we are very pleased with how well this tool works (thank you Squarespace!). Squarespace remains our website host and provider.
For those of you who use the forums regularly, if you bookmarked specific URLs on the old site, you will likely need to update those links. The forums continue to be hosted on Squarespace 5 as they do not have the forum function within the Squarespace 7 environment as yet. The previous forums resided on youreatopia.squarespace.com and the new forums are now ediforums.squarespace.com. Unfortunately, the former site will not resolve to the new site, however all the content from the forums remains completely intact. It means that if you were used to just going directly to the forums site, you will need to use the new ediforums.squarespace.com URL to get there directly. Of course you can also get to the forums directly using Visit Forums. If you're new and know nothing of our forums, then you'll find information under Community in the menu bar, HDRM Recovery Group Forums.
If you are already a registered member, then you remain one and nothing has effectively changed for the forums with the exception of the name change for the site.
The main Your Eatopia site will completely resolve to the new Eating Disorder Institute site, so bookmarks from that site should work to take you to the same material on the new site here.
More Brand Name Changes
The next big news is the renaming of the MinnieMaud Guidelines to the Homeodynamic Recovery Method (HDRM). Our white rabbit (with the green outline) remains as the logo for HDRM, but the new name reflects more accurately the holistic scope of the recovery method outlined on this site. For more information, please visit the Homeodynamic Treatment Method under Treatment in the menu bar.
There is also a new brand you’ll be seeing more of on the Eating Disorder Institute site in the months and years to come: the peacock of Anicca Managed Active Care. While the focus is, and will remain, the pursuit of full remission from eating disorders here at The Eating Disorder Institute, we intend to provide more information and materials that would be relevant for those needing to manage an active state of an eating disorder. While remission from an eating disorder is always possible at any age or stage of the condition, it is not always feasible. Many with active and enduring eating disorders quite rightly feel marginalized within the eating disorder treatment spaces both online and in real life.
The more that those who must navigate an active state of the condition are provided with information on harm reduction and protection of quality of life, then the more likely they may find themselves in a space where an effort towards full remission becomes feasible. But even when it remains outside the realm of feasibility, through absolutely nothing within the patient’s control, they deserve the opportunity to protect their health and quality of life as this should be an innate right for any patient.
I realize that this might make community members of this site a bit nervous—that information on harm reduction might detract from the focus on remission that has been the exclusive space of this site and its forums. However, the forums remain an HDRM-only space (meaning they remain for those pursuing full remission only). For posts that specifically speak to harm reduction, they will be clearly marked as AMAC material with the peacock as the logo to look for if such information is relevant to you. This is material that will be developed over the months and years to come.
Skrifa is Old Norse for “writing.” As there are several heavily referenced, long format documents I have created over the years that provide in-depth information on recovery, I have split out what was once just a blog into categories that better reflect the topics covered on our site: Papers, Conferences, Obesity, Psychology, First Person and Blog.
With the exception of the Fat Series, all other posts now have embedded references at the end of each post. The Fat Series will have references added at a later date.
The Phases of Recovery post is now a thoroughly updated 5-part in-depth series providing comprehensive information on the various facets of recovery.
One on One
The One on One e-mail service is now active again. For those unfamiliar with the service, it allows for you to receive specific input from me (the founder here at the Eating Disorder Institute) on any questions you may have about recovery that you can subsequently review with your in-person treatment team. It is a fee-for-service offering. However if you take the time, you’ll likely find the answers to your questions (for free) in the Skrifa section on this site.
The videos that were available explaining the basics of recovery have now been removed from this site and the accompanying YouTube channel. There will be new videos made available at a later date to replace the ones that are now unavailable.
The SEARCH tool will enable you to find things if you were used to the previous site and are trying to find things here on the new site.
Once a year, on our anniversary, we usually activate a Donate Button for just one week. As you likely all know, this site has no advertising or financial revenue sources beyond the one-time $5 fee that is assigned for access to the forums as well as the One on One service.
If you feel so inclined, your support is gratefully accepted and allows for us to continue to maintain this informational site.
Thank you for your continuing support and I hope that you will be as thrilled with this new site as I am!
Lots of unpleasant, painful and upsetting symptoms occur in recovery that are the result of the damage an active eating disorder causes to the body. Acne is just one of several symptoms that show up for many during the recovery process. And of course, the unsurprising solution often suggested by both medical and alternative healthcare providers will be to remove food groups (most commonly sugar and/or milk products). Removing food groups reduces mortality outcomes for everyone, and is particularly damaging for those with eating disorders as restriction of any kind precipitates relapse of the eating disorder. 1, 2, 3
Chris Piascik: Flickr.com
The hormone known to be a key player in the pathogenesis of acne is dehydroepiandrosterone (DHEA). In fact dehydroepiandrosterone sulphate (DS) can be found in concentrated levels in pre-menarchical young girls who present with acne. 4 What this means is that pubertal development will temporarily mix up the various androgen and estrogen levels and the acne resolves with sexual maturation.
It is common for patients undergoing recovery from eating disorders to have a period of severe acne and it coincides with something akin to going through puberty yet again as the body re-establishes its natural sex hormone balance.
“Compared with healthy women, both AN and BN patients exhibited increased plasma levels of 3α,5α-THP, DHEA, DHEA-S, and cortisol but reduced concentrations of 17β-estradiol.” 5
The above quote reflects that under the duress of restricting energy intake, cortisol (the stress hormone suite) is high, androgens are high and estrogens are low. That will create a predisposition for the presence of acne. It suggests that both during the time when a patient is actively restricting and when she enters recovery, acne may be present as a direct result of the impact of restriction on both stress and reproductive hormones in the body.
Treatment for acne has historically involved broad-spectrum antibiotics as there is a bacterium intimated in the pathogenesis of the condition, namely Propionibacterium acnes (P. acnes). However, recent dermatology association position papers recommend the use of oral contraceptives (either in the presence or absence of excess androgens) for women. In fact P. acnes is more of a symbiont than pathogen and is responsible for the breakdown of oils to provide the skin with natural moisturizer. However different strains of P. acnes appear to generate distinctly different inflammatory responses within the pilosebaceous follicle of the skin. 6 Recent clinical studies suggest that acne is an inflammatory skin disorder where genetic, hormonal and presumably the strain of P. acnes all play a part in its pathogenesis for individual patients. 7 This recent understanding may explain why antibiotic treatment (either topical or broad spectrum pill form) is falling out of favor in up-on-the-research dermatology circles: it really is a rather ham-fisted smack down of a normally symbiotic bacterium at the end of a chain of immunoendocrinological anomalies that will not address the underlying anomalies.
Let’s just take a moment to consider the complexity of the appearance of acne: sexual hormonal development and maturation, circulating levels of stress hormones, as well as possible genetic, inflammatory and pathogenic inputs all appear to need to be present for acne to show up. And yet we figure that cutting out sugar or milk will be just the ticket to fix it all—it’s a wonderful example of “when all you have is a hammer, everything looks like a nail”.
But why take my obviously biased opinion of the uselessness of dietary restriction as a cure in this case? Let’s look at systematic reviews in peer-reviewed published scientific literature instead.
Despite the poor design and short follow-up of a few studies in the 1960s and 70s, up to 72% of the general population still believes that chocolate bars, peanuts, cheeses, fats and sugars contribute to the onset of acne. 8, 9
In one systematic review, the authors were able to locate one retrospective study that suggested dairy consumption was linked to acne during the teen years. As you all know, retrospective studies rely on the subjects’ recall and therefore provide quite questionable data given our memories are always highly suspect. The correlation itself was also weak and interestingly a bit stronger (in relative terms) for skim milk products: 1.12 for whole milk; 1.16 for low-fat milk; and 1.44 for skim milk. 10 The children of the subjects in this original retrospective epidemiological survey were then prospectively studied (meaning they were surveyed moving forward in time rather than having them depend upon memory recall). 11, 12 And the same correlation of around 1.19 showed up.
Here’s what the authors of this systematic review had to say regarding these epidemiological studies:
“On the basis of these results, the authors speculate that the nonfat portion of milk contains hormones and bio-active molecules, such as androgens, progesterone, and insulin growth factor-1 (IGF-1), that can have an acne- stimulating effect. These cohort studies, however, can only suggest correlation but not causation. Family history of acne and other possible confounding factors such as steroid use were not included in the analysis. In addition, though the children graded their amount of acne on a five-category scale, investigators did not examine if the amount of milk intake correlated with acne severity.” 13
Just as a refresher, a correlation that ups the risk of acne onset from 1.00 (the point at which there is no link between the items being studied) and 1.19 or even 1.44 is statistically significant but not clinically significant. In other words, when you are a real patient and not a statistic, this correlation is so tiny as to be irrelevant to your experience. Furthermore, having only two epidemiological surveys means that there is no way any relevant conclusion can be drawn regarding this presumed correlation. But if you want to use this questionable data then the take home message might be stick to whole milk products.
What do the clinical trial data say about sugar and acne onset? Within this same systematic review I am quoting, the authors reference only one randomized investigator-masked, controlled trial with 43 males ages 15 to 25. Both the study group placed on a high-protein low-glycemic index diet and the control group (no special diet) had a reduction in total lesion counts. In real numbers, the study group experienced 21.9 fewer lesions and the control group experienced 13.8 fewer lesions—or essentially 8 fewer acne pimples (lesions) for the study group compared to the control group. 14 The authors of the systematic review had this to say regarding the results:
“However, the LGL [low-glycemic load] group also had a significant reduction in weight and BMI [body mass index]. Weight loss is known to decrease circulating androgen and insulin levels; thus, whether the skin improvements were due to the dietary differences or the concomitant weight reduction is unclear.” 15
Weight loss is not sustainable for 99.997% of the population (see here). Those with eating disorders who choose to remove sugar (a low-glycemic index diet) from their diets to treat acne will have the opportunity to perhaps experience 8 fewer acne lesions and risk full-blown relapse of the eating disorder as well.
I understand that it’s hard not to go and play in the sandbox of dietary silliness along with the rest of our misguided society, but honestly it’s not just an unpleasant place to be, it’s also downright dangerous if you have an eating disorder.
What are you supposed to do if you have a painful and severe outbreak of acne while you are in recovery from an active eating disorder? You can most certainly see your doctor or dermatologist to discuss whether oral contraceptives might be an option for you. Oral contraceptives do not interfere with your body’s ability to continue along its recovery path and they may help reduce the acne outbreak while your stress and reproductive hormones sort themselves out.
Beyond that, don’t underestimate how relevant psychoeducational treatment can be (seeing a therapist). I am not saying that the acne outbreak is treatable in this way; I am however saying that relaxation techniques and learning to handle the distress of approaching and eating the food with guidance from an appropriately trained therapist will lower stress hormone levels over time and we know that these hormones are one contributory facet of the onset of acne for most. 16 Some decent studies suggest that various forms of yoga breathing have a direct impact on lowering cortisol, DHEA and adrenocorticotropic (ATCH) levels. 17, 18, 19 There are also smatterings of clinical data on the use of both biofeedback and hypnosis for improving the severity of acne as well. 20
As with all other distressing symptoms in recovery, time is the most powerful mediator in resolving the symptom completely for almost everyone. No one wants to hear that, but it’s true.
1. Kant, Ashima K., Barry I. Graubard, and Arthur Schatzkin. "Dietary patterns predict mortality in a national cohort: the National Health Interview Surveys, 1987 and 1992." The Journal of nutrition 134, no. 7 (2004): 1793-1799.
2. Klopp, Sheree A., Cynthia J. Heiss, and Heather S. Smith. "Self-reported vegetarianism may be a marker for college women at risk for disordered eating." Journal of the American Dietetic Association 103, no. 6 (2003): 745-747.
3. Kadambari, Rao, Simon Cowers, and Arthur Crisp. "Some correlates of vegetarianism in anorexia nervosa." International Journal of Eating Disorders 5, no. 3 (1986): 539-544.
4. Lucky, Anne W., Frank M. Biro, Gertrude A. Huster, Alan D. Leach, John A. Morrison, and Joan Ratterman. "Acne vulgaris in premenarchal girls: an early sign of puberty associated with rising levels of dehydroepiandrosterone." Archives of dermatology 130, no. 3 (1994): 308-314.
5. Monteleone, Palmiero, Michele Luisi, Barbara Colurcio, Elena Casarosa, Patrizia Monteleone, Raffaele Ioime, Andrea R. Genazzani, and Mario Maj. "Plasma levels of neuroactive steroids are increased in untreated women with anorexia nervosa or bulimia nervosa." Psychosomatic Medicine 63, no. 1 (2001): 62-68.
6. Nagy, István, Andor Pivarcsi, Andrea Koreck, Márta Széll, Edit Urbán, and Lajos Kemény. "Distinct strains of Propionibacterium acnes induce selective human β-defensin-2 and interleukin-8 expression in human keratinocytes through toll-like receptors." Journal of Investigative Dermatology 124, no. 5 (2005): 931-938.
7. Holland, Diana B., and Anthony HT Jeremy. "The role of inflammation in the pathogenesis of acne and acne scarring." In Seminars in cutaneous medicine and surgery, vol. 24, no. 2, pp. 79-83. WB Saunders, 2005.
8. Al-Hoqail, Ibrahim A. "Knowledge, beliefs and perception of youth toward acne vulgaris." Saudi medical journal 24, no. 7 (2003): 765-768.
9. Rigopoulos, D., S. Gregoriou, A. Ifandi, G. Efstathiou, S. Georgala, J. Chalkias, and A. Katsambas. "Coping with acne: beliefs and perceptions in a sample of secondary school Greek pupils." Journal of the European Academy of Dermatology and Venereology 21, no. 6 (2007): 806-810.
10.Adebamowo, Clement A., Donna Spiegelman, F. William Danby, A. Lindsay Frazier, Walter C. Willett, and Michelle D. Holmes. "High school dietary dairy intake and teenage acne." Journal of the American Academy of Dermatology 52, no. 2 (2005): 207-214.
11. Adebamowo, Clement A., Donna Spiegelman, Catherine S. Berkey, F. William Danby, Helaine H. Rockett, Graham A. Colditz, Walter C. Willett, and Michelle D. Holmes. "Milk consumption and acne in teenaged boys." Journal of the American Academy of Dermatology 58, no. 5 (2008): 787-793.
12.Adebamowo, Clement A., Donna Spiegelman, Catherine S. Berkey, F. William Danby, Helaine H. Rockett, Graham A. Colditz, Walter C. Willett, and Michelle D. Holmes. "Milk consumption and acne in adolescent girls." Dermatology online journal 12, no. 4 (2006).
13. Tom, Wynnis L., and Victoria R. Barrio. "New insights into adolescent acne." Current opinion in pediatrics 20, no. 4 (2008): 436-440.
14.Smith, R., N. Mann, A. Braue, H. Makelainen, and G. Varigos. "The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: A randomized, investigator-masked, controlled trial." Journal of the American Academy of Dermatology 57, no. 2 (2007): 247-256.
15. Tom, Wynnis L., and Victoria R. Barrio. "New insights into adolescent acne." Current opinion in pediatrics 20, no. 4 (2008): 436-440.
16. Chiu, Annie, Susan Y. Chon, and Alexa B. Kimball. "The response of skin disease to stress: changes in the severity of acne vulgaris as affected by examination stress." Archives of dermatology 139, no. 7 (2003): 897-900.
17. Sulekha, Sathiamma, Kandavel Thennarasu, Appajachar Vedamurthachar, Trichur R. Raju, and Bindu M. Kutty. "Evaluation of sleep architecture in practitioners of Sudarshan Kriya yoga and Vipassana meditation*." Sleep and Biological Rhythms 4, no. 3 (2006): 207-214.
18. Narnolia, Pramod Kumar, Bijender Kumar Binawara, Akhil Kapoor, Mamata Mehra, Manoj Gupta, Khemlata Tilwani, and Sitaram Maharia. "Effect of Sudarshan Kriya Yoga on Cardiovascular Parameters and Comorbid Anxiety in Patients of Hypertension."
19. Vedamurthachar, A., Nimmagadda Janakiramaiah, Jayaram M. Hegde, Taranath K. Shetty, D. K. Subbakrishna, S. V. Sureshbabu, and B. N. Gangadhar. "Antidepressant efficacy and hormonal effects of Sudarshana Kriya Yoga (SKY) in alcohol dependent individuals." Journal of affective disorders 94, no. 1 (2006): 249-253.
20. Shenefelt, Philip D. "Biofeedback, cognitive‐behavioral methods, and hypnosis in dermatology: Is it all in your mind?." Dermatologic Therapy 16, no. 2 (2003): 114-122.
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