Crystal, my other RD half over at Real Life Women’s Health is back today with a post for you on a frequently requested topic – managing anxiety in ED recovery. Also, if you don’t already, you can follow her on instagram for a bunch of other good stuff. Enjoy!
Happy Friday Everyone! This was a tricky one to write because it’s not directly nutrition related. That being said, it most certainly affects food choices and all other aspects of life. And it’s just so important.
I wanted to write this post for a few reasons. All of my clients have anxiety to some degree. It’s something that comes up a lot in sessions and can be a big roadblock. I’ve also dealt with varying degrees of anxiety myself and know that so many other women do too. So we certainly aren’t alone!
In fact, anxiety often presents itself prior to the onset of an eating disorder with 55-62% of women also having a comorbid anxiety diagnoses. Most commonly: obsessive compulsive disorder, social phobia, and generalized anxiety disorder. Interesting, right?
Anxiety and Eating Disorders
Some studies show rates of anxiety in anorexia nervosa and bulimia nervosa as high as 60-80%. And roughly ⅔ of the time, the anxiety first appears in childhood. Even if you haven’t been given a diagnoses, anxiety can still be present and interfere with recovery from an eating disorder.
It’s important for practitioners to understand why their clients experience anxiety, how that must feel for them, and how the anxiety fits into their treatment. It’s also helpful for those in recovery (and those who aren’t!) to bring awareness to their feelings of anxiety, to feel supported, and to be able to work with their team to cope with the anxiety so that recovery doesn’t feel out of reach.
Keep in mind that anxiety will often increase as ED behaviors decrease. This is because your emotions are more raw and intense. You’re letting go of unhelpful coping mechanisms that numbed you out, but haven’t yet nailed down new, more helpful coping mechanisms. In time, you will, but this “inbetween phase” can feel frustrating.
Hang in there. Working with a team who can support you during this time is crucial. Anxiety can feel overwhelming and make the recovery process really difficult if you don’t have strategies and support in place.
Origins of Anxiety
We’ve probably all experienced anxiety in our lives, but where does anxiety come from anyway?
One theory is that anxiety used to serve an important purpose for our ancestors. It was meant to keep us alive. (More on that here.) In the internal family systems (IFS) model, anxiety would be seen as a “part” of us just like you might have a sad part or a perfectionist part.
From this lens, anxiety is serving a purpose and maybe it’s just gotten to an extreme level that is no longer helpful. The goal isn’t to completely rid yourself of anxiety – which is an unreasonable expectation. Instead, the goal is to get curious and discover what it’s doing for you. Rather than pushing the anxiety away, you’d welcome the anxiety in and ask what it needs. Maybe it’s protecting you from something. Or maybe it just needs to know that you’re okay and you can handle the situations in your life.
If you’ve seen the movie Inside Out (great movie!), it’s similar to that where these sub-personalities develop from somewhere (often during childhood) and they all have a reason for being there.
Just like eating disorders, the origins of anxiety are thought to be biopsychosocial involving genetics, neurology and environment.
Eating Disorders as Anxiety Disorders
Want to keep nerding out? Let’s keep going… Norman Kim is a PhD who has done great work in the eating disorders community. He is among a large group of professionals who see eating disorders as anxiety disorders. He talks more about this in detail on these podcasts: ED Catalogue and Recovery Warriors. I’ll just summarize some of the discussion below in case you’re wanting the cliff notes version:
- All eating disorders involve anxiety of some kind.
- After weight restoration and working on eating disorder recovery, anxiety often remains.
- Fear or anxiety attached to food goes deeper than being afraid of gaining weight and often is attached to feelings of disgust – which is rooted in anxiety.
- Anxiety creates a drive to feel better. And if the only thing that helps to quell that is engaging in ED behaviors, it perpetuates the disorder.
- One treatment that is successfully used for OCD is called Exposure Response Prevention. This involves learning through experience that feared consequences don’t occur.
Exposure Response Prevention
An example of this would be eating a “fear food” and realizing that it doesn’t cause a catastrophic event.
He makes the point that avoidance increases anxiety in the long term, even if it feels better short-term. (I’m sure many of us can relate to this outside of food and body image too.) The more you repeat behaviors, the more it drives you to do them. The only way to stop that cycle is to not engage in the behavior.
He uses the analogy of learning to swim, ride a bike or drive a car. Initially, you probably had some anxiety or fear around these things. But the more you actively do them, the less anxiety you’ll experience. This reminds me of roller coasters because they terrify me. But when I have gone on them, the anxiety I felt beforehand always goes away and it ends up being fun!
If you’d like more detailed info on the origins of anxiety check out the references for more articles on this topic. Now that we have a bit of background on anxiety, let’s talk about what we can do. Here are the practical tips!
Below, I’ve listed a few tried-and-true treatment strategies for coping with anxiety. This is by no means an exhaustive list. If you’re feeling overwhelmed by all the tips, start with one and experiment with it for a week or two. Then move on and try something else. I would love to hear if you have other ways that help you with your anxiety in the comments!
Fluoxetine (Prozac), which increases serotonin levels, is most commonly used across all eating disorders. It’s also the only antidepressant approved by the USDA to treat bulimia. Medication doesn’t mean you aren’t “strong enough” to fight anxiety on your own. Instead, think of it as another helpful tool in your toolbox. Think of it as an assistant to all of the hard cognitive work you are doing. Sometimes medication is needed to take the edge off so you can actually do the deeper cognitive work. We have medication for a reason!
Turning traits that encourage anxiety (like perfectionism and harm-avoidance) into advantages so they become beneficial can be really helpful. For example, perfectionism around food leads to rigidity and restriction. In other areas of life, like school or career, perfectionism can be a positive trait if it’s managed well.
L-theanine, amino acids, Omega 3s, and magnesium. All of these can be helpful when managing anxiety. Talk with your dietitian to see if any of these are right for you and for recommendations on dosage.
Ashwagandha, holy basil, lavender, chamomile and passionflower are some herbs that show potential benefits for anxiety. Again, talk with a knowledgeable healthcare professional before incorporating any of these into your routine.
Mindfulness can look different for different people. Some great examples are: being in nature, meditating, yoga, deep breathing, and using essential oils.
A note on meditating –> You don’t have to sit quietly for 30 minutes to get the benefits. And it doesn’t have to be some mega zen experience. Even pausing throughout the day to stay present in what you’re doing helps. One or two slow, deep breaths to ground yourself is helpful too. It’s human nature to think constantly – we have 50,000-70,000 thoughts a day! So if you are brushing your teeth, doing dishes or grocery shopping – actively try to stay in the moment rather than let your thoughts take over. Remember, this is a process and thoughts WILL pop up, but the act of refocusing on the task at hand soothes the brain.
Autonomous Sensory Meridian Response (ASMR)
Research is still emerging on this. ASMR describes the experience of tingling sensations on the crown of the head in response to a range of audio-visual triggers like whispering, tapping and hand movements. Anecdotally, viewers use videos (often found on YouTube) to trigger ASMR and promote relaxation and sleep. Some people even use it as an antidote to depression and anxiety.
One example of ASMR is watching the oil painting time lapse video I mentioned. You can also try this video of someone drawing a map. There are some odd videos out there so just a heads up! 😉
Gentle movement like walking or yoga can often help calm anxiety. Before adding this to your routine, check with your dietitian. Depending on your stage of recovery, this may not be appropriate.
Reduce or eliminate caffeine intake. Too much caffeine can heighten anxiety. That being said, you should remember that each person has a different tolerance. Experiment with when and how much caffeine you drink and observe how you feel.
This means eating a wide variety of foods, eating enough and eating frequently. These are all very important in order to support our sympathetic (fight or flight) system and keep blood sugar stable.
I’m a big fan of therapy for anyone. Working through emotions and managing anxiety with a therapist is a must in recovery. Various approaches used include CBT, DBT, ACT, IFS, and exposure response prevention.
Taking care of yourself and tuning into your body’s needs looks different for everyone. It can include things like adequate nutrition, rest, taking time to do things you enjoy, reading, watching a movie or TV show, painting or drawing, playing an instrument, seeing friends and family, taking time for yourself, etc. Another great idea is to create a self care box!
Reaching out to friends, family, and other people who are going through a similar experience or who have recovered can be very helpful.
Clean up your feed and unfollow any toxic accounts that increase anxiety and ED thoughts. If an account doesn’t help you live a better life, unfollow.
If you’ve never done this before, know that it can be very therapeutic to get all your thoughts out of your head and onto paper. There is a great book on journaling by Katie Dalebout that can be found here.
Sit With Your Anxiety
Last but certainly not least – sitting with it. Instead of acting on an ED behavior urge, you can actively choose not to by breaking the cycle. You will experience discomfort doing this, but think of the urge like a wave you are riding. Anxiety will often subside once you realize nothing catastrophic happens when you resist the urge.
I also love this list of lesser known strategies for coping with anxiety.
I truly hope this information was helpful. Know that you are not alone. Anxiety disorders affect 18% (40 million) of adults in the United States. We can actively choose to understand and manage anxiety. It’s not something that has to hinder recovery or your life!
Poerio GL, Blakey E, Hostler TJ, Veltri T. More than a feeling: Autonomous sensory meridian response (ASMR) is characterized by reliable changes in affect and physiology. Aspell JE, ed. PLoS ONE. 2018;13(6):e0196645. doi:10.1371/journal.pone.0196645.
Su K-P, Matsuoka Y, Pae C-U. Omega-3 Polyunsaturated Fatty Acids in Prevention of Mood and Anxiety Disorders. Clinical Psychopharmacology and Neuroscience. 2015;13(2):129-137. doi:10.9758/cpn.2015.13.2.129.