Lifetime Eating Disorders Three
Separating Interoception from Anxiety
As you already know, an eating disorder really sits under the wide umbrella of anxiety disorder, more specifically similar to phobias.
Anxiety is an emotional state that exists for survival. Its activation drives us to put our senses on high alert; to survey everything; to assess the relevance of what our senses are telling us; and then to act if we have identified a threat (or threats) that must be addressed.
Anxiety, at its most useful, is an awareness module in our brains. Anxious people hear, smell and see things others with lower and slower anxiety systems just don’t notice. Anxious people are the sentinel meercats of the human world.
Anxious people activate interpretation of all their senses. One of those senses is designed to survey the world within. Interoception is the ability to sense and interpret what’s going on in your body: are you tired, hungry, thirsty, is there pain, itchiness, cold, heat, is the heart racing, etc.
Interoception is a double-edged sword for someone with an eating disorder. Not taking in enough energy blunts all our senses, our cognition and our emotions. If you have intellect to spare, then the cognitive hit of an eating disorder is likely not noticeable to anyone and maybe not even be to yourself. You likely appear to the outside world as competent, in control and decidedly chill.
As you begin to refeed, your brain (cognition, emotion and the interpreter of your senses) comes back online. If you have ever seen any videos of people who have cochlear implants and they are tested for hearing for the first time, invariably they burst into tears upon hearing the sound of their loved ones’ voices. This is often interpreted as joy or happy tears, but in fact it’s more of a physiological flooding response. If it were possible to implant an ability to sense magnetic north, as do birds, or see colours in the spectrum that bees or hummingbirds can detect, we would likely all have the same flooding. The brain has this sudden new sense that it has to integrate for interpretation. Even for someone who perhaps once was able to hear and illness removed that sense, the suddenness of its return would still generate a strong reaction.
Every twinge, grumble, itch, ache and pain will ratchet the check-again loop in the brain when you begin refeeding on any level. And as an eating disorder is an anxiety disorder, the novel data coming in from everywhere to the brain will be interpreted as a threat.
That “something is not right” signal then gets filtered through conscious evaluation in the brain. Unfortunately, the delineation between something actually happening that requires immediate medical attention to the myriad things that will resolve of their own accord, is an odds game. The vast majority of the time, it needs to be left alone to resolve.
There is the symptom, then there is the agitation you feel about the symptom. The symptom itself may be worth ignoring, watching it to see if it worsens, or seeking immediate intervention. Those are the choices before you when you register, through interoception, some novel symptom in your body.
Distinct from that, is the emotional interpretation of that symptom. The check-again loop, the worry, the agitation, the irritation, the distress are all emotional cascades that have nothing to do with the choice to ignore, watch, or seek medical advice.
Anxiety has both a functional and a dysfunctional side to it. When anxiety is applied as an early warning detection system whose function is to drive an action or decision, then it’s useful.
Anxiety, in its dysfunctional space, drives repetitive avoidance. No matter what novel symptom you face when you approach and eat food, there are only ever three actions to consider: ignore, wait or get medical attention. That’s it. If you are cutting back on the intake of food to compensate for eating something, or adding exercise minutes and intensity, or purging, etc., then that is when anxiety has become a dysfunctional force in your life.
Additionally, food itself has been misidentified as a threat for those with eating disorders. That means that even in the absence of any physical symptoms during refeeding that might trigger avoidance of food, the food itself generates a tremendous cascade of agitation and fear.
If you want to incrementally apply some recovery efforts in a slower way, the secret to that having any success at all will be two-fold: 1) you reject all avoidance and compensation behaviours in response to the physiological and emotional impacts of approaching and eating food, and 2) you refuse to get comfortable and commit to regularly increasing your food intake to challenge the avoidance behaviours further.
Restricting Food is the Bad Anxiety
A very large chunk of the submissions I receive with questions around recovery challenges all fall within the confusion of distinguishing between adaptive and maladaptive anxiety.
“Is this symptom a threat in my specific case? It feels like a threat. Does this mean that I am the exception and I cannot recover in the way everyone else does?” etc.
At no point is restriction the action that must be applied in response to any symptoms in recovery. Even if refeeding syndrome shows up, the treatment protocol is not to reduce food intake, but to add life-saving electrolytes to the system (immediate medical intervention for that). And even if, by some fluke of rare coincidences you begin recovery, get bitten by a disease-carrying tick and subsequently develop a red meat allergy, you will have to replace red meat in the diet and not that you are now required to restrict food intake overall. Food allergies are increasingly more common—I’m talking allergies and not intolerances. Intolerances are best treated with enzymatic supplementation (like secondary lactose intolerance). Many food allergies, by contrast, are life threatening. But food allergies are about replacement and not restriction. By all means don’t eat a food that could actually kill you (!), but when you have an eating disorder your threat identification system is profoundly over-active so it’s important to always refer to your food allergy as needing replacement foods, not food avoidance or restriction. A gluten-free cake has replacement ingredients for gluten. A chicken burger would be a replacement for a beef burger for someone with a red meat allergy. You get the idea.
If you have symptoms suggesting an actual food allergy: hives, shortness of breath, wheezing, swelling of face, throat, then those do require immediate medical intervention. But, when you have an eating disorder, it will also require a lot of post-crisis conscious effort to keep the bad anxiety from driving you back to broad food avoidance behaviours. Replacement strategies are key to the onset of a novel food allergy.
Whether you are 29 or 89, there are two things that are not options for managing symptoms as you go through recovery from an eating disorder: restricting food and exercise.
If your medical treatment team is recommending food restriction or exercise for whatever condition has appeared, then you have to advocate as someone might around being allergic to penicillin and yet who needs antibiotics for an infection. You have to advise the medical team that restricting food or introducing regular exercise will trigger relapse of your eating disorder and you’d like their input on whatever other options they might have for managing the symptoms or condition that has appeared and is causing everyone concern.
We will look at medical advice in more depth in the next series coming up.
