Dr: “Are you eating?”
Me: “Yes”
Dr: “Hmm … Well. you are still very underweight, so maybe try eating a bit more?”
Me: “Sure, I’ll try that.”
What my Dr never asked me about was the extent that I was exercising. I was eating, but that was on the condition that I exercised for over six hours a day. In a sense, my Anorexia was hiding in plain sight. I was eating. I could not be accused of not eating. As excessive exercise was not listed as a symptom of Anorexia, however, I evaded diagnosis despite presenting at a ludicrously low weight.
This blog is about the importance of recognizing exercise as a symptom of a restrictive eating disorder. Sadly, even through the importance of recognizing exercise as a problem in Anorexia has been documented for over 20 years, it is still slipping under the radar.
I talk about the exercise component to my eating disorder with a passion because it was the hardest part for me to overcome, and I still think it is the least understood by the majority of treatment professionals and even those of us who suffer from restrictive eating disorders ourselves. I think that if people really “got” the OCD element of Anorexia, then they would understand that the compulsive exercise should be treated in the same way any other OCD behaviour should be treated. And how do you stop an OCD behaviour? You STOP or redirect the behavior. For me this meant going cold turkey on the exercise, which was utterly terrifying.
That in itself sounds ridiculous to admit. I found the prospect of not exercising terrifying. I’m not exaggerating when I say it was the hardest thing I have done in my entire life. I’ve jumped huge, fixed, wooden fences with ditches underneath at a gallop on a horse many times. I’ve skied off a cornice in a whiteout. Neither of these experiences come even close to the thought of not exercising when I was sick.
Currently the exercise recommendation is a murky grey area in terms of the advice that eating disorder professionals and therapists give people. Most people in recovery from Anorexia are not told anything about whether or not they should exercise. Some are told “moderate.” Some are told to abstain. Some therapists don’t even ask (don’t expect us to volunteer information on how much exercise we do!) This should not be a murky grey area. This should be crystal clear. Nobody in recovery from a restrictive eating disorder should be exercising. It is a symptom of the illness. It is compulsive. It is OCD (study here that explores that idea nicely). It is as bad for us as purging is. It is purging in disguise.
Can you imagine a person in treatment for Bulimia being told “purge moderately,” or, “purge a couple of times a week.” Sounds whack, right? Well, this is the advice we are often given to people with Anorexia about exercise.
Purging is not such a grey area because it is an overtly undesirable behaviour. Whereas exercise is considered a desirable behaviour for the general population. For a person with an eating disorder, however, it can be compulsive — as can all types of movement. I don’t just mean going to the gym and running either. For a person with an eating disorder, walking the dog or vacuuming the house can be compulsive.
Most people don’t understand that even when I had given up (or been thrown out of) the gym and had stopped formal exercise, the compulsion to move continued to exist in practically every move I made. Taking the longer route. Walking rather than taking the car. Getting up and down to fetch things when eating a meal. Never sitting. Always having to stand. Fidgeting. I was not allowed to sit down during the day. If I had to (say a car ride or a situation where I could not stand) I would have to “make it right” by eating less that day. I believe that this is due to the energy-deficit generated OCD that accompanies the illness very strongly for many of us.
This is hideous to live through. I wanted nothing more than to be able to stop moving. I couldn’t stop moving. I couldn’t even admit to wanting to stop moving in my own head as that felt like some sort of sin in itself. There were too many things dependent on me keeping moving. Mostly my ability to eat at all. It was all conditional. I got to eat only if I had moved enough that day.
The very thought of not doing my walks, routines, exercise during the day could reduce me to tears. I was scared shitless of not exercising. I think in a messed up way, my brain understood that my ability to eat was tethered to my movement conditions, and so it was terrified of not doing these things as it knew if I didn’t I would not eat. And my body was too underweight to not eat. So I was scared of not meeting the conditions as I was scared that would mean I would not be able to eat and a part of me knew that was very bad news because I was already dangerously underweight. That was one source of fear — and a slightly more rational one. The other source of fear was tied into the “weight gain” fear which is utterly irrational as I never, ever liked being underweight. Anorexia gave me a very inappropriate fear response at the thought of weight gain.
Exercise often starts out well intended
Exercise started out innocently well intended for me. I started exercising to make me feel better and it did at first. Initially, exercising also allowed me to eat slightly more. I thought this was a good thing. However, it was only a couple of weeks before exercise had switched to voluntary and helpful to involuntary and detrimental. It no longer made me feel good. That effect had vanished.
Many of us with Anorexia start off straight restricting. We don’t eat. I was in this camp for the first year or so of my illness. Most of the adults whom I work with also at onset of the illness were straight restriction. If we are lucky, we are given treatment at that time that is effective and that is as far as it gets.
As the years in the illness go on, many of us begin exercising. It is estimated up to 80 percent of people with AN have a compulsive exercise problem. It reduces anxiety at first. It never stays that way. It turns into something almost greater than restricting food for many of us. Another reason we pick exercising up is because purely restricting is not sustainable. We need to find something that allows us some food but doesn’t cause weight gain. Messed up I know, but that is what my brain was telling me when I started a gym membership. Or for some, exercise is introduced because restricting alone is not enough to appease the eating disorder’s demands for weight loss.
This can work the other way around. I know people also for whom AN started with exercise rather than food restriction initially. This doesn’t even have to be weight-reduction focused exercise. I know peeps who have innocently thought it would be a good idea to join a gym in order to tone up a bit who have developed AN due to unintentional energy deficit and weight loss.
Compulsive movement in children too young to understand the idea that exercise causes energy deficit is very telling too. Really shows how the disorder generates the compulsion even when the brain doesn’t have a logical explanation for it.
The paths to compulsive movement may be different, but the devastating and exhausting result is the same: we become utterly dependent on exercise/movement.
Depression
Very interesting ideas from a study that looked into the differences between levels of depression high level and low level exercisers in people with Anorexia.
Several studies have shown that exercise has a positive impact on a variety of psychological disorders. Nevertheless, the increased amount of daily activity in the high-level AN exercisers was not sufficient to suppress their levels of depression to values of low-level AN exercisers or controls. In addition to the aspect and function of comorbid depression in association with pattern of high-level exercise as well as an association with binge/purge behaviour additional aspects e.g. level of impulsivity, might help to characterize AN patients to identify more homogenous endophenotypes of AN patients. From an evolutionary point of view, this hyperactivity could be a result of food search behavior]. If in the long-term this is not rewarded by the intake of a substantial amount of food, this phenomenon could explain the increased observed depression in this subgroup.
This addresses the notion that we exercise in order to increase positive mood — an excuse I myself clung on to for years. If I were asked why I ran so much, I would answer that it made me feel better. In truth, I don’t know that this is the case and I suspect that this answer came from something I had heard somewhere about exercise being an anti-depressant. Let’s be clear: I exercised because I had to. I could kid myself that it was because I wanted to, but that doesn’t make it true.
As the study quoted above found levels of depression were higher among AN patients with high-level activity than among AN patients with low level activity. Ha … but that is a chicken or egg discussion! Do those of us who exercise a lot have higher pre levels of depression, or does the exercise induce higher levels of depression due to increased physical depletion?
My personal experience would have been the latter. I have never suffered depression other than the sort that hit about a year into my excessive exercise regime.
One problem with studying these sorts of effects is self-reporting requires us to i) have a level of self awareness that anosognosia often doesn’t allow for, and ii) be truthful about our motivations.
For example, even if I did know that deep down I was exercising because I didn’t have the option or control not to, rather than because it lifted my mood, it would still have been truthful for me to give the answer that I exercised because it made me feel better. That was arguably true either way, but “making me feel better because it lifts my mood,” is different from “making me feel better because even the thought of not exercising makes me feel anxious to the point of suicidal.”
There are theories that we exercise to self medicate. Reduce depression. This may be the original motivation, but in my experience with myself and with those whom I work with, as time goes by exercising doesn’t continue to have this effect. It still makes us feel better, but not in the same way. More in the way that you put clothes on in the morning to avoid feeling all the negativity that might ensue if you were to waltz into work starkers. You don’t put clothes on because it makes you feel “better” you do it because it is required in order to keep everything on the level it currently is.
Try this: Imagine something that you do every day, just like the idea above of putting clothes on, that makes you feel panicked, nauseous, and extremely anxious were I to tell you “You cannot do that thing tomorrow.”
Now to give you some context, I will tell you that I would have chosen hands down forgoing clothing in favor of forgoing exercising. That is how big a deal this was for me.
So the idea that we do it to reduce depression makes sense, but it doesn’t quite hit the mark with me. The understanding is in the details.
The difference here, is that the exercise is being done to maintain a less anxious state rather than to reduce anxiety. Or said differently, to not exercise would create almost unbearable anxiety and fear. It was less the case that exercising lifted my mood and more the case that exercising was something I had to do in order to keep my head above water.
In a sense, after a couple of years, exercising increased my levels of depression because it made me feel more trapped. However, the thought of not exercising was enough to make me feel panicked and, admittedly, suicidal. Exercise was no longer a case of negative state relief. It was more a case of survival.
Sometimes mentally accepting cold turkey is the hardest part
It took me a couple of years to get to cold turkey. Two years from deciding I wanted to stop exercising to actually stopping exercising. It was incredibly hard to do, as I had built my identity around exercising. I was working as a personal trainer — spending all day every day in a gym. Even worse, I was making a fair bit of money doing it. Anorexia told me I was never going to be good enough at anything else, and that if I gave up my gym career I would end up destitute. Anorexia will say anything to keep one trapped.
I tried initially to stop exercising myself while still working in a gym. That was a disaster and I failed miserably. That is the Anorexia version of an alcoholic working in a brewery. Conversely when I tried to stop exercising without changing my lifestyle things got worse because every day Anorexia told me today was my “last fling” and I would stop exercising tomorrow, and so ironically I ended up doing more, not less. Tomorrow never comes.
As I describe in detail in my book I finally stopped suddenly one day. That day was both the worst and best day of my life. Worst because of the place I had to go mentally in order to make the decision to stop exercising. Best because stopping was the first day of my recovery.
What this means in recovery
Here’s the deal: You can weight restore while still exercising. Of course you can. If you eat enough food, your body will gain weight regardless of how much exercise you do because that is the underweight body’s priority. For this reason, many people argue that they don’t need to stop exercise in order to “recover.”
No. Because recovery is not just weight restoration and getting weight restored doesn’t equal full recovery. Full recovery is the ability to eat without conditions and without fear. Exercise = conditions. In order to be able to eat without conditions, you have to be able to stop exercising and not reduce your intake. It is compulsive and you are not in control. If you were in control, stopping would not make you want to cry and scream.
If you have managed to weight restore but are still exercising: Firstly, good on you for weight restoring — that’s a big deal! Now for the rest of the work. Rest.
It’s not fair. But you have to stop. The biggest irony for me, was that while stopping was so hard, and felt so unfair when I was underweight, after a year or so of not exercising I didn’t want to start it up again. Now, weight restored for years and fully recovered, I can exercise if I want to, but I rarely bother. There is so much more to life.
You have to rest.