Doctor EDNOS
August 14, 2015 10:09 PM
I am at a very, very demanding point in my career and am struggling with some variant of disordered eating. Complicating factors: underlying medical problem, minority, demanding and erratic job schedule.
I am struggling with some variant of disordered eating. Not outright eating disorder, because I don't fit DSM criteria for anything other than the NOS category, and I'm a normal weight, but something is nonetheless definitely off about my eating habits. I have a distant history of eating disorder in my preteen years, which mostly disappeared by itself once I was in a less stressful living environment.
Part of this is that I have a medical condition that is making me gain a lot of weight regardless of what I eat. I do feel like this is a huge part of what started it all: I feel like I cannot trust my body to not gain a zillion pounds by simply eating like a normal person. I feel bloated 90% of the time unless I fast (which does make me feel good and more positive about eating normal meals, but then I struggle with swinging the other way too much ("well, I didn't eat for a long time so I can overeat at this meal") especially if I eat that fast-breaking meal alone). One thing that does work is if I have fasted and then eat a normal meal with people-- that seems to reduce the behavior as well.
Another part of it is all the free food we get from lunch meetings. I end up compulsively collecting leftover food so that I can pick at it in private and throw most of it away after dissecting it. Additionally, I have the ability to regurgitate my swallowed food very easily. I recently found out that I could help this process along by drinking a ton of water to bring up any "residual" food. It has gotten worse, to the point where I will take my own food that I've purchased from the grocery store and I'll chew and spit a large amount of food into empty water bottles or plastic bags. Gross, I know. This sucks away a lot of time and it's a drag on my life. I have noticed that it gets worse if I eat when I am not physically hungry. If I eat when I am actually hungry, I'm fine, pleased that I have eaten a decent meal, and do not engage in the behavior nearly as much. I live alone, far from my friends and family, which is good and bad -- nobody to police my eating behaviors, but nobody to enjoy a normal meal with, either. I feel like I have nothing to look forward to in my life other than tomorrow's lunch menu.
My job is stressful, which probably also contributes to my eating behaviors. Additionally, I don't know if I have time to find a therapist and actually go to therapy due to the demands of my job; my schedule is erratic (I'm on call all the time) and I generally work from 6 AM to 8 PM 6-7 days a week in a town that otherwise strictly operates 8-5. My days off are spent catching up on much-needed sleep. I don't want my behavior to be overly pathologized in my medical record, especially after seeing how psych patients are treated by most physicians in other specialties (the EMR is linked). I'm in a very white place (think Iowa or the Dakotas) and I am a minority that is seen by white people as being "tiny" (seriously, I get unsolicited comments on how "tiny" I am in this town even after having gained a ton of weight due to my medical condition; in my ethnic group I am considered overweight). I don't know if I'd even want to explain my background to a white therapist. When I was not as busy, I tried going to a counselor in the past for this and looking past the minority aspect of things, but it ended up not working out as I hoped because ... honestly, he just wasn't very bright. Another therapist turned me down because she said "to treat an eating disorder, you need to be seen at least three times a week." That's not going to work for me.
Has anybody else made it through intern year (or any other very demanding point in one's career) with some form of disordered eating? What did you do to manage it? I am sick of feeling this way. I am wasting a ton of food.
Throwaway email is melogrammatic15 at gmail dot com. At worst, I can probably live like this for one year, at which point my professional demands should be somewhat lessened schedule-wise. It has not interfered with my job performance. However, I would like to stop with this ridiculous behavior. Thank you for your help.
I am struggling with some variant of disordered eating. Not outright eating disorder, because I don't fit DSM criteria for anything other than the NOS category, and I'm a normal weight, but something is nonetheless definitely off about my eating habits. I have a distant history of eating disorder in my preteen years, which mostly disappeared by itself once I was in a less stressful living environment.
Part of this is that I have a medical condition that is making me gain a lot of weight regardless of what I eat. I do feel like this is a huge part of what started it all: I feel like I cannot trust my body to not gain a zillion pounds by simply eating like a normal person. I feel bloated 90% of the time unless I fast (which does make me feel good and more positive about eating normal meals, but then I struggle with swinging the other way too much ("well, I didn't eat for a long time so I can overeat at this meal") especially if I eat that fast-breaking meal alone). One thing that does work is if I have fasted and then eat a normal meal with people-- that seems to reduce the behavior as well.
Another part of it is all the free food we get from lunch meetings. I end up compulsively collecting leftover food so that I can pick at it in private and throw most of it away after dissecting it. Additionally, I have the ability to regurgitate my swallowed food very easily. I recently found out that I could help this process along by drinking a ton of water to bring up any "residual" food. It has gotten worse, to the point where I will take my own food that I've purchased from the grocery store and I'll chew and spit a large amount of food into empty water bottles or plastic bags. Gross, I know. This sucks away a lot of time and it's a drag on my life. I have noticed that it gets worse if I eat when I am not physically hungry. If I eat when I am actually hungry, I'm fine, pleased that I have eaten a decent meal, and do not engage in the behavior nearly as much. I live alone, far from my friends and family, which is good and bad -- nobody to police my eating behaviors, but nobody to enjoy a normal meal with, either. I feel like I have nothing to look forward to in my life other than tomorrow's lunch menu.
My job is stressful, which probably also contributes to my eating behaviors. Additionally, I don't know if I have time to find a therapist and actually go to therapy due to the demands of my job; my schedule is erratic (I'm on call all the time) and I generally work from 6 AM to 8 PM 6-7 days a week in a town that otherwise strictly operates 8-5. My days off are spent catching up on much-needed sleep. I don't want my behavior to be overly pathologized in my medical record, especially after seeing how psych patients are treated by most physicians in other specialties (the EMR is linked). I'm in a very white place (think Iowa or the Dakotas) and I am a minority that is seen by white people as being "tiny" (seriously, I get unsolicited comments on how "tiny" I am in this town even after having gained a ton of weight due to my medical condition; in my ethnic group I am considered overweight). I don't know if I'd even want to explain my background to a white therapist. When I was not as busy, I tried going to a counselor in the past for this and looking past the minority aspect of things, but it ended up not working out as I hoped because ... honestly, he just wasn't very bright. Another therapist turned me down because she said "to treat an eating disorder, you need to be seen at least three times a week." That's not going to work for me.
Has anybody else made it through intern year (or any other very demanding point in one's career) with some form of disordered eating? What did you do to manage it? I am sick of feeling this way. I am wasting a ton of food.
Throwaway email is melogrammatic15 at gmail dot com. At worst, I can probably live like this for one year, at which point my professional demands should be somewhat lessened schedule-wise. It has not interfered with my job performance. However, I would like to stop with this ridiculous behavior. Thank you for your help.
Every behavior, action, serves a function, even if that function is at cross-purposes with what it seeks to remedy. Even if the remedy is worse than the causal ailment.
Right now, it's difficult to acknowledge and manage all of the stressors in your life. In metaphorical language, you feel depleted, hungry, and undernourished. You find your "spare time" allows only for sleep. That is a difficult place to be. On top of that, you feel isolated and far from home. Are there ways to connect with people where you are?
It sounds like many variables in your life feel out of your control. I want to reflect that it is quite stressful right now for you. Without judging the current behavior that you don't want, what else could you try in addition to that coping mechanism?
A few things: it sounds like you are disconnected from your body, disconnected from your time, disconnected from the physical place in which you find yourself, and disconnected from your feelings. The ability to take time to care for yourself and the nonlinear time on which our emotions operate (including experiencing them, the time required for discerning and noticing the surfacing of feelings, and the nonlinear and idiosyncratic ways in which emotional healing take place) do not fit neatly into the realm of 9-5 (like the hours of your town), or your long work shifts.
Strategies: Books. Little daily meditation-a-day books. Affirmation-a-day books. Quick things that aren't a hassle, but that give you a bit of grounding.
Mindfulness. Do you ever listen to mindfulness talks? Ways to bring your mind and thoughts back to your body? Little by little, so that it's tolerable. It didn't take one day for this behavior to present itself as a coping mechanism, and generally behaviors that we find aren't the best for us, or aren't working for us work until they don't. You may need to dance with this behavior for a little while until it truly goes away. It could spontaneously resolve itself after the first intense intern year is over. It could be something that arose specifically because it seems like the best thing to help you get through this right now, even if you know it's not the best for you. We could call this a harm reduction approach.
Worry about "wasting food" later. It is good, though, to recognize when something is not working and when you want to change.
There is a website that is very compassionate and intelligent: Body Positive. It's where I first discovered the transtheoretical model of change, which posits that change is nonlinear. We pre-contemplate, contemplate, sometimes revert back to the old behavior, and so on. There's also a maintenance component. Resource yourself; look it over and see what you think.
It's never useful when people say, "Don't be so hard on yourself," because it seems to just batten down the hatches and doesn't really offer solutions. You are hard on yourself. You push yourself hard, too. You don't show weak spots, except to yourself and alone. It's perhaps partly why you find yourself with the disordered eating when you are alone. It's not about diagnosing yourself, though. It's not about a diagnosis, it's not about labeling. It's about figuring out what is and is not working for you, and figuring out a way to live in a more self-accepting way in relationship with yourself as you move through the world and work toward your goals.
Right now you are valuing your career. That is your priority and important.
Part of balancing that is to balance your emotional and physical needs for connection, for nourishment (in all forms), and in physical expression. If you are good with routines and schedules, perhaps you could join a mindfulness group. One that allows you to be on the periphery and doesn't require that you participate in a draining way, but where your presence is safe and invited.
A sense of humor. What makes you laugh? I'm not saying everything is funny, but there is something comical about days, about the absurdity of this thing called being human and being alive. Text book examples don't do justice to the oddness of human life and what is called health. Take comfort in the writings of other physicians, or just thoughtful, erudite, or plain funny people. Writers. Their experiences. It may help you to know that other people went through this, too, and lived to tell the tale. And suffered. And made weird choices that helped them through it. Even if it hurt. Like that recent essay by Oliver Stone, where he was an amphetamine addict for a while, alone and depressed and isolated.
I also think that no therapist is better than a bad therapist. But having someone to talk with, that process of looking for someone with whom you actually connect? That is important and while it may take time, especially given the demographics of where you currently find yourself, it's also very worthwhile and you deserve that. Be angry about the microaggressions you experience and find allies, try to find your people. It takes time. The ugly duckling didn't almost freeze in the middle of a pond during winter without its context of being constantly searching for what fit it, instead of trying to fit where it found itself. But persist.
It's not easy to learn how to self-soothe, how to nourish ourselves, and how to find connection that connects to us in all of the ways in which we wanted to be connected. Like the adage about treating people the way that they want to be treated. Nuanced like that.
Don't blame the behavior. And if you can find someone to talk with about it, someone whom you trust, that is a good thing. Keep looking for that. In the meantime, you have options and control and volition. Remember that you always have choices. And remember that change is a process. Kindness and courage.
posted by simulacra at 12:32 AM on August 15, 2015
Right now, it's difficult to acknowledge and manage all of the stressors in your life. In metaphorical language, you feel depleted, hungry, and undernourished. You find your "spare time" allows only for sleep. That is a difficult place to be. On top of that, you feel isolated and far from home. Are there ways to connect with people where you are?
It sounds like many variables in your life feel out of your control. I want to reflect that it is quite stressful right now for you. Without judging the current behavior that you don't want, what else could you try in addition to that coping mechanism?
A few things: it sounds like you are disconnected from your body, disconnected from your time, disconnected from the physical place in which you find yourself, and disconnected from your feelings. The ability to take time to care for yourself and the nonlinear time on which our emotions operate (including experiencing them, the time required for discerning and noticing the surfacing of feelings, and the nonlinear and idiosyncratic ways in which emotional healing take place) do not fit neatly into the realm of 9-5 (like the hours of your town), or your long work shifts.
Strategies: Books. Little daily meditation-a-day books. Affirmation-a-day books. Quick things that aren't a hassle, but that give you a bit of grounding.
Mindfulness. Do you ever listen to mindfulness talks? Ways to bring your mind and thoughts back to your body? Little by little, so that it's tolerable. It didn't take one day for this behavior to present itself as a coping mechanism, and generally behaviors that we find aren't the best for us, or aren't working for us work until they don't. You may need to dance with this behavior for a little while until it truly goes away. It could spontaneously resolve itself after the first intense intern year is over. It could be something that arose specifically because it seems like the best thing to help you get through this right now, even if you know it's not the best for you. We could call this a harm reduction approach.
Worry about "wasting food" later. It is good, though, to recognize when something is not working and when you want to change.
There is a website that is very compassionate and intelligent: Body Positive. It's where I first discovered the transtheoretical model of change, which posits that change is nonlinear. We pre-contemplate, contemplate, sometimes revert back to the old behavior, and so on. There's also a maintenance component. Resource yourself; look it over and see what you think.
It's never useful when people say, "Don't be so hard on yourself," because it seems to just batten down the hatches and doesn't really offer solutions. You are hard on yourself. You push yourself hard, too. You don't show weak spots, except to yourself and alone. It's perhaps partly why you find yourself with the disordered eating when you are alone. It's not about diagnosing yourself, though. It's not about a diagnosis, it's not about labeling. It's about figuring out what is and is not working for you, and figuring out a way to live in a more self-accepting way in relationship with yourself as you move through the world and work toward your goals.
Right now you are valuing your career. That is your priority and important.
Part of balancing that is to balance your emotional and physical needs for connection, for nourishment (in all forms), and in physical expression. If you are good with routines and schedules, perhaps you could join a mindfulness group. One that allows you to be on the periphery and doesn't require that you participate in a draining way, but where your presence is safe and invited.
A sense of humor. What makes you laugh? I'm not saying everything is funny, but there is something comical about days, about the absurdity of this thing called being human and being alive. Text book examples don't do justice to the oddness of human life and what is called health. Take comfort in the writings of other physicians, or just thoughtful, erudite, or plain funny people. Writers. Their experiences. It may help you to know that other people went through this, too, and lived to tell the tale. And suffered. And made weird choices that helped them through it. Even if it hurt. Like that recent essay by Oliver Stone, where he was an amphetamine addict for a while, alone and depressed and isolated.
I also think that no therapist is better than a bad therapist. But having someone to talk with, that process of looking for someone with whom you actually connect? That is important and while it may take time, especially given the demographics of where you currently find yourself, it's also very worthwhile and you deserve that. Be angry about the microaggressions you experience and find allies, try to find your people. It takes time. The ugly duckling didn't almost freeze in the middle of a pond during winter without its context of being constantly searching for what fit it, instead of trying to fit where it found itself. But persist.
It's not easy to learn how to self-soothe, how to nourish ourselves, and how to find connection that connects to us in all of the ways in which we wanted to be connected. Like the adage about treating people the way that they want to be treated. Nuanced like that.
Don't blame the behavior. And if you can find someone to talk with about it, someone whom you trust, that is a good thing. Keep looking for that. In the meantime, you have options and control and volition. Remember that you always have choices. And remember that change is a process. Kindness and courage.
posted by simulacra at 12:32 AM on August 15, 2015
Some thoughts about aiming to (really just barely, maybe, try to) handle this in the very very short term (by which I mean less than this year, more on which later) :
- Get appropriate treatment for the medical issue relating to the bloating and weight.
- Why do you eat when you're not physically hungry? Boredom? Loneliness? Stress*? Try to identify alternative ways of managing these. Do yoga (for the breathing), go for a walk in the park, call a friend or family member. Taking a stress management course might at least offer a few ideas, even if they're not ED-specific.
- However - is there an ED-specific self-help (peer-led) group you could attend, maybe evenings?
- It's not really the lunches, it's your response to the lunches and your overall situation. But don't linger after meetings end. Walk straight out (if you can).
- For other meals, eat among people as much as possible - cafes, restaurants. I'd suggest getting a roommate, for the sake of an audience that would set the stage for inhibition of this behaviour, but I'm not sure it'd be fair to them, quite honestly. It'd be a burden for someone who's not close to you to worry about, if they got an idea of what is happening.
- WRT ethnicity and weight - I appreciate that what you're talking about reflects cultural standards. But, and I don't know if this applies, there may be some actual ethnicity-specific differences wrt BMI calculations and other indices of health/overweight/obesity and various health risks. Maybe that applies. If so, find the research and bring it in, if you do speak to a therapist. If it doesn't apply, find the ethnographic research on different cultural standards and pass that along.
Sounds like your job is going to continue to be stressful for the foreseeable, even if the scheduling lessens a bit. Your performance isn't suffering now. But it probably will, maybe before the year is up. This is some kind of stress response that, I agree with you (though IANAD/P), must be pathological in some way (it is impairing, distressing to you, reduces your quality of life, and is frankly outside the bounds of what is generally considered normal behaviour).
Change the stress to the degree that you can. I think it is worth actually making different life choices wrt your job that significantly reduce this kind of stress, if this is happening. But if that's not on the table - maybe you don't have to be the best person around, if you're putting that kind of additional pressure on yourself. Maybe you can do a just a good job, and still have a good career.
And, sorry - get appropriate help for the pathological response. Yes, it's probably going to be on your record, and you'll have to deal with that. That's the tradeoff, I wish it weren't. Maybe the provider will be understanding, and record a diagnostic category that you feel is possibly less stigmatizing, while treating you for this. You could ask. Or, you could dig deep and go private. If the evidence says it takes three times a week to get the right help, I think you need to make time for it. If you can get any help, maybe with a therapist over the phone, try that as well, it's probably better than nothing.
Finally: your health is more important than any job, any career.
posted by cotton dress sock at 12:35 AM on August 15, 2015
- Get appropriate treatment for the medical issue relating to the bloating and weight.
- Why do you eat when you're not physically hungry? Boredom? Loneliness? Stress*? Try to identify alternative ways of managing these. Do yoga (for the breathing), go for a walk in the park, call a friend or family member. Taking a stress management course might at least offer a few ideas, even if they're not ED-specific.
- However - is there an ED-specific self-help (peer-led) group you could attend, maybe evenings?
- It's not really the lunches, it's your response to the lunches and your overall situation. But don't linger after meetings end. Walk straight out (if you can).
- For other meals, eat among people as much as possible - cafes, restaurants. I'd suggest getting a roommate, for the sake of an audience that would set the stage for inhibition of this behaviour, but I'm not sure it'd be fair to them, quite honestly. It'd be a burden for someone who's not close to you to worry about, if they got an idea of what is happening.
- WRT ethnicity and weight - I appreciate that what you're talking about reflects cultural standards. But, and I don't know if this applies, there may be some actual ethnicity-specific differences wrt BMI calculations and other indices of health/overweight/obesity and various health risks. Maybe that applies. If so, find the research and bring it in, if you do speak to a therapist. If it doesn't apply, find the ethnographic research on different cultural standards and pass that along.
Sounds like your job is going to continue to be stressful for the foreseeable, even if the scheduling lessens a bit. Your performance isn't suffering now. But it probably will, maybe before the year is up. This is some kind of stress response that, I agree with you (though IANAD/P), must be pathological in some way (it is impairing, distressing to you, reduces your quality of life, and is frankly outside the bounds of what is generally considered normal behaviour).
Change the stress to the degree that you can. I think it is worth actually making different life choices wrt your job that significantly reduce this kind of stress, if this is happening. But if that's not on the table - maybe you don't have to be the best person around, if you're putting that kind of additional pressure on yourself. Maybe you can do a just a good job, and still have a good career.
And, sorry - get appropriate help for the pathological response. Yes, it's probably going to be on your record, and you'll have to deal with that. That's the tradeoff, I wish it weren't. Maybe the provider will be understanding, and record a diagnostic category that you feel is possibly less stigmatizing, while treating you for this. You could ask. Or, you could dig deep and go private. If the evidence says it takes three times a week to get the right help, I think you need to make time for it. If you can get any help, maybe with a therapist over the phone, try that as well, it's probably better than nothing.
Finally: your health is more important than any job, any career.
posted by cotton dress sock at 12:35 AM on August 15, 2015
Sacks. Oliver Sacks. I had ~24 seconds to edit that post and, sadly, my brain went to "Oliver Stone".
Here is the Oliver Sacks essay [excerpt follows].
posted by simulacra at 12:49 AM on August 15, 2015
Here is the Oliver Sacks essay [excerpt follows].
After I qualified as a doctor in 1960, I removed myself abruptly from England and what family and community I had there, and went to the New World, where I knew nobody. When I moved to Los Angeles, I found a sort of community among the weight lifters on Muscle Beach, and with my fellow neurology residents at U.C.L.A., but I craved some deeper connection — "meaning" — in my life, and it was the absence of this, I think, that drew me into near-suicidal addiction to amphetamines in the 1960s.It's okay to be hungry. And to want. And sometimes the things that save us come in the oddest forms, like in the form of curiosity, or great heart toward a life meaning, figuring out one's vocation and latching onto it even when nothing else makes sense. And that is a lucky thing, indeed. But it takes time.
Recovery started, slowly, as I found meaningful work in New York, in a chronic care hospital in the Bronx (the "Mount Carmel" I wrote about in "Awakenings"). I was fascinated by my patients there, cared for them deeply, and felt something of a mission to tell their stories — stories of situations virtually unknown, almost unimaginable, to the general public and, indeed, to many of my colleagues. I had discovered my vocation, and this I pursued doggedly, single-mindedly, with little encouragement from my colleagues. Almost unconsciously, I became a storyteller at a time when medical narrative was almost extinct. This did not dissuade me, for I felt my roots lay in the great neurological case histories of the 19th century (and I was encouraged here by the great Russian neuropsychologist A. R. Luria). It was a lonely but deeply satisfying, almost monkish existence that I was to lead for many years.
posted by simulacra at 12:49 AM on August 15, 2015
I have a friend who counsels clients via Skype - here's an article (not connected with my friend): http://www.theatlantic.com/health/archive/2014/12/the-skype-psychologist/382910/.
Maybe you could find someone who is more culturally competent and available at odd hours that way.
posted by lakeroon at 3:42 AM on August 15, 2015
Maybe you could find someone who is more culturally competent and available at odd hours that way.
posted by lakeroon at 3:42 AM on August 15, 2015
When I was at a point where my eating disorder was wearing me down and I was ready to begin being done with it - but not ready to actually deal with the deep-seated and shameful feelings I had around food and my body, or talk about it in therapy - I found the writings of Ellyn Satter and the Fat Nutritionist (who follows a lot of Ellyn Satter's philosophies) really helpful.
Reading this stuff didn't change my life instantly. In fact, I hit a wall of "this sounds so nice but it's not for me, because I am too [bad/fat/inferior/fucked up already] to be allowed something this nice". But the ideas stuck with me, and when there was more space in my life and my brain later on they lodged a bit more firmly and I began to feel more comfortable applying these radical ideas about food and bodies (radical in the sense that they go completely against the prevailing messages society sends to women about food and appearance) to myself.
The other thing that really helps is living with someone who cares that I am nourished regardless of what I look like, and who would be very aware if my eating habits changed. It's not just not living alone (I was able to hide a ton of behaviour when I lived with housemates), it's specifically the relationship with the person I'm living with. I realise that this is not an immediate or easy thing to achieve.
posted by terretu at 8:48 AM on August 15, 2015
Reading this stuff didn't change my life instantly. In fact, I hit a wall of "this sounds so nice but it's not for me, because I am too [bad/fat/inferior/fucked up already] to be allowed something this nice". But the ideas stuck with me, and when there was more space in my life and my brain later on they lodged a bit more firmly and I began to feel more comfortable applying these radical ideas about food and bodies (radical in the sense that they go completely against the prevailing messages society sends to women about food and appearance) to myself.
The other thing that really helps is living with someone who cares that I am nourished regardless of what I look like, and who would be very aware if my eating habits changed. It's not just not living alone (I was able to hide a ton of behaviour when I lived with housemates), it's specifically the relationship with the person I'm living with. I realise that this is not an immediate or easy thing to achieve.
posted by terretu at 8:48 AM on August 15, 2015
This thread is closed to new comments.
posted by taz at 12:23 AM on August 15, 2015