Accompanying with the steady increase in the number of people with eating disorders has been a rise in the number of people with exercise disorders: people who are controlling their bodies, altering their moods, and defining themselves through their overinvolvement in exercise activity, to the point where instead of choosing to participate in their activity, they have become "addicted" to it, continuing to engage in it despite adverse consequences. If dieting taken to the extreme becomes an eating disorder, exercise activity taken to the same extreme may be viewed as an activity disorder, a term used by Alayne Yates in her book Compulsive Exercise and the Eating Disorders (1991).

In our society, exercise is increasingly being sought, less for the pursuit of fitness or pleasure and more for the means to a thinner body or sense of control and accomplishment. Female exercisers are particularly vulnerable to problems arising when restriction of food intake is combined with intense physical activity. A female who loses too much weight or body fat will stop menstruating and ovulating and will become increasingly susceptible to stress fractures and osteoporosis. Yet, similar to individuals with eating disorders, those with an activity disorder are not deterred from their behaviors by medical complications and consequences.

People who continue to overexercise in spite of medical and/or other consequences feel as if they can't stop and that participating in their activity is no longer an option. These people have been referred to as obligatory or compulsive exercisers because they seem unable to "not exercise," even when injured, exhausted, and begged or threatened by others to stop. The terms pathogenic exercise and exercise addiction have been used to describe individuals who are consumed by the need for physical activity to the exclusion of everything else and to the point of damage or danger to their lives.

The term anorexia athletica has been used to describe a subclinical eating disorder for athletes who engage in at least one unhealthy method of weight control, including fasting, vomiting, diet pills, laxatives, or diuretics. For the rest of this chapter, the term activity disorder will be used to describe the overexercising syndrome as this term seems most appropriate for comparison with the more traditional eating disorders.

Signs and Symptoms of Activity Disorder

The signs and symptoms of activity disorder often, but not always, include those seen in anorexia nervosa and bulimia nervosa. Obsessive concerns about being fat, body dissatisfaction, binge eating, and a whole variety of dieting and purging behaviors are often present in activity disordered individuals. Furthermore, it is well established that obsessive exercise is a common feature seen in anorexics and bulimics; in fact, some studies have reported that as many as 75 percent u and se excessive exercise as a method of purging and/or reducing anxiety. Therefore, activity disorder can be found as a component of anorexia nervosa or bulimia nervosa or, although there is yet no DSM diagnosis for it, as a separate disorder altogether.

There are many individuals with the salient features of an activity disorder who do not meet the diagnostic criteria for anorexia nervosa or bulimia nervosa. The overriding feature of an activity disorder is the presence of excessive, purposeless, physical activity that goes beyond any usual training regimen and ends up being a detriment rather than an asset to the individual's health and well-being.

In her book, Compulsive Exercise and the Eating Disorders, Alayne Yates lists the proposed features of an activity disorder, a summary of which is listed below.

Features of an Activity Disorder

• The person maintains a high level of activity and is uncomfortable with states of rest or relaxation.
• The individual depends on the activity for self-definition and mood stabilization.
• There is an intense, driven quality to the activity that becomes self-perpetuating and resistant to change, compelling the person to continue while feeling the lack of ability to control or stop the behavior.
• Only the overuse of the body can produce the physiologic effects of deprivation (secondary to exposure to the elements, extreme exertion, and rigid dietary restriction) that are an important component perpetuating the disorder.
• Although activity disordered individuals may have coexisting personality disorders, there is no particular personality profile or disorder that underlies an activity disorder. These persons are apt to be physically healthy, high-functioning individuals.
• Activity disordered persons will use rationalizations and other defense mechanisms to protect their involvement in the activity. This may represent a preexisting personality disorder and/or be secondary to the physical deprivation.
• Although there is no particular personality profile or disorder, the activity disordered person's achievement orientation, independence, self-control, perfectionism, persistence, and well- developed mental strategies can foster significant academic and vocational accomplishments in such a way that they appear as healthy, high-functioning individuals.

Activity disorders, like eating disorders, are expressions of and defenses against feelings and emotions and are used to soothe, organize, and maintain self-esteem. Individuals with the eating disorders and those with activity disorders are similar to one another in many respects. Both groups attempt to control the body through exercise and/or diet and are overly conscious of input versus output equations. They are extremely committed individuals and pride themselves on putting mind over matter, valuing self-discipline, self-sacrifice, and the ability to persevere.

They are generally hard-working, task-oriented, high-achieving individuals who have a tendency to be dissatisfied with themselves as if nothing is ever good enough. The emotional investment these individuals place on exercise and/or diet becomes more intense and significant than work, family, relationships, and, ironically, even health. Those with activity disorders lose control over exercise just as those with an eating disorder lose control over eating and dieting, and both experience withdrawal when prevented from engaging in their behaviors.

Individuals with anorexia nervosa and bulimia nervosa and those with activity disorders usually score high on the EDI subscales of perfectionism and asceticism and have similar distortions in their cognitive (thinking) styles. The following list includes examples of the thinking patterns of people with activity disorders that are similar to the mental distortions in those with eating disorders.

Medical Reference from "The Eating Disorders Sourcebook"

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Cognitive Distortions in Activity Disorder

DICHOTOMOUS, BLACK-AND-WHITE THINKING

• If I don't run, I can't eat.
• I either run an hour or it's not worth it to run at all.

OVERGENERALIZATION

• Like my Mom, people who don't exercise are fat.
• Not exercising means you are lazy.

MAGNIFICATION

• If I can't exercise, my life will be over.
• If I don't work out today, I'll gain weight.

SELECTIVE ABSTRACTION

• If I can go to the gym, I am happy.
• I feel great when I exercise, so if I exercise I'll never be depressed.

SUPERSTITIOUS THINKING

• I must run every morning or something bad will happen.
• I must do 205 sit-ups every night.
• I can't stop at 1 hour and 59 minutes, it has to be exactly 2 hours, so when the fire alarm went off I couldn't get off the Stairmaster, I had to keep going, even if the gym was burning down.

PERSONALIZATION

• People are looking at me because I'm out of shape.
• People admire runners.
• I am a runner, it's who I am, I could never give it up.

ARBITRARY INFERENCE

• People who exercise get better jobs, relationships, and so on.
• People who exercise don't get sick as much.

DISCOUNTING

• My doctor tells me not to run, but she is flabby so I don't listen to her.
• No pain, no gain.
• Nobody really knows the effects of not having a period anyway, so why should I worry?

Physical Symptoms of Activity Disorder

• A key in determining if a person is developing an activity disorder is if she has the symptoms of overtraining (listed below) yet persists with exercise anyway. Overtraining syndrome is a state of exhaustion in which individuals will continue to exercise while their performance and health diminish. Overtraining syndrome is caused by a prolonged period of energy output that depletes energy stores without sufficient replenishment.

Symptoms of Over-Training

• Fatigue
• Reduction in performance
• Decreased concentration
• Inhibited lactic acid response
• Loss of emotional vigor
• Increased compulsivity
• Soreness, stiffness
• Decreased maximum oxygen uptake
• Decreased blood lactate
• Adrenal exhaustion
• Decreased heart rate response to exercise
• Hypothalamic dysfunction
• Decreased anabolic (testosterone) response
• Increased catabolic (cortisol) response (muscle wasting)

The only cure for the above symptoms is complete rest, which may take a few weeks to a few months. To a person with activity disorder, resting is like giving up or giving in. This is similar to an anorexic who feels like eating is "giving in." When giving up their exercise behaviors, those with activity disorder will go through psychological and physical withdrawal, often crying, yelling, and making statements like

• I can't stand not exercising, it's driving me crazy, I'd rather die.
• I don't care about the consequences, I have to work out or I'll turn into a fat blob, hate myself, and fall apart.
• This is worse torture than any effects of the exercise, I feel like I'm dying inside.
• I can't even stand being in my own skin, I hate myself and everyone else.

It is important to note that these feelings diminish over time but need to be carefully attended to.

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Approaching an Individual With an Activity Disorder

In January 1986, the Physician and Sports Medicine Journal discussed the subject of pathogenic (negative) exercise in athletes and listed recommendations for approaching athletes practicing one or more pathogenic weight control techniques. The recommendations can be reformulated and extended for use when approaching individuals with activity disorders who are not necessarily considered athletes.

Guidelines for Approaching the Activity Disordered Individual

• A person who has good rapport with the individual, such as a coach, should arrange a private meeting to discuss the problem in a supportive style.
• Without judgment, specific examples should be given regarding the behaviors that have been observed that arouse concern.
• It is important to let the individual respond but do not argue with him or her.
• Reassure the individual that the point is not to take away exercise forever but that participation in exercise will ultimately be curtailed through an injury or by necessity if evidence shows that the problem has compromised the individual's health.
• Try to determine if the person feels that he or she is beyond the point of being able to voluntarily abstain from the problem behavior.
• Do not stop at one meeting; these individuals will be resistant to admitting that they have a problem, and it may take repeated attempts to get them to admit a problem and/or seek help.
• If the individual continues to refuse to admit that a problem exists in the face of compelling evidence, consult a clinician with expertise in treating these disorders and/or find others who may be able to help. Remember that these individuals are very independent and success oriented. Admitting they have a problem they are unable to control will be very difficult for them.
• Be sensitive to the factors that may have played a part in the development of this problem. Activity disordered individuals are often unduly influenced by significant others and/or coaches who suggest that they lose weight or who unwittingly praise them for excessive activity.

Risk Factors

One outstanding difference between the eating disorders and activity disorders seems to be that there are more males who develop activity disorders and more females who develop eating disorders. Exploring the reason for this may provide a better understanding of both. What are the causes that contribute to the development of an activity disorder? Why do only some individuals with eating disorders have this syndrome and others who have this syndrome don't have eating disorders at all? What we do know is that the risk factors for developing an activity disorder are varied, including sociocultural, family, individual, and biological factors, and are not necessarily the same ones that cause the disorder to persist.

Sociocultural

In a society that places a high value on independence and achievement combined with being fit and thin, involvement in exercise provides a perfect means for fitting in or gaining approval. Exercise serves to enhance self-worth, when that self-worth is based on appearance, endurance, strength, and capability.

Family

Child-rearing practices and family values contribute to an individual choosing exercise as a means of self-development and recognition. If parents or other caregivers endorse these sociocultural values and they themselves diet or exercise obsessively, children will adopt these values and expectations at an early age. Children who learn not only from society but also from their parents that to be acceptable is to be fit and thin may be left with a narrow focus for self-development and self-esteem. A child reared with phrases such as "no pain, no gain," may endorse this attitude wholeheartedly without the proper maturity or common sense to balance this notion with proper self- nurturing and self-care.

Individual

Certain individuals seem predisposed to need a high level of activity. Individuals who are perfectionists, achievement oriented, and have the capacity for self-deprivation will be more likely to seek out exercise and become addicted to the feelings or other perceived benefits the exercise provides. Additionally, individuals who develop activity disorder seem outwardly independent, unstable in their view of themselves, and lacking in their ability to have fully satisfying relationships with others.

Biological

Just as with eating disorders, researchers are exploring what biological factors may contribute to activity disorders. We know that certain individuals have a biologically based predisposition to obsessive thoughts, compulsive behaviors, and, in women, amenorrhea. We know that in animals the combination of food restriction and stress causes an increase in activity level and, furthermore, that food restriction with increased activity can cause the activity to become senseless and driven.

Furthermore, parallel changes have been detected in the brain chemicals and hormones of eating disordered females and long-distance runners that may explain how the anorexic tolerates starvation and the runner tolerates pain and exhaustion. In general, activity disordered men and women seem to be different biochemically than nondisordered individuals and are more easily led and trapped into a cycle of activity that is resistant to intervention.

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Treatment for an Activity Disorder

The principles of treatment for individuals with activity disorders are similar to those with eating disorders. Medical issues must be handled, and residential or inpatient treatment may be necessary to curtail the exercise and to deal with depression or suicidality, but most cases should be able to be treated on an outpatient basis unless the activity disorder and an eating disorder coexist. This combination can present a serious situation rather quickly. When lack of nutrition is combined with hours of exercise, the body gets broken down at a rapid pace, and residential or inpatient treatment is often required.

Sometimes hospitalization is encouraged to patients as a way to relieve the vicious cycle of nutrient deprivation combined with exercise before a breakdown occurs. Activity disordered individuals often recognize that they need help to stop and know that they cannot do it with outpatient treatment alone. Eating disorder treatment programs are probably the best choice for hospitalizing those with activity disorder. An eating disorder facility that has a special program for athletes or compulsive exercisers would be ideal. (See the description of The Monte Nido Residential Treatment Facility on pages 251 - 274).

Therapy for an Activity Disorder

It is important to keep in mind that activity disordered people tend to be highly intelligent, internally driven, independent individuals. They will most likely resist any kind of vulnerability such as going for treatment unless they become injured or face some kind of ultimatum. Excessive activity protects these individuals against desiring to get close, to take in something from another, or to depend on anyone.

Therapists will have to maintain a calm, caring stance with the goal of helping the individual define what he or she needs, rather than focusing on taking things away. Another therapeutic task is to help the individual receive and internalize the soothing functions the therapist can provide, thus promoting relationships over activity.

THERAPEUTIC ISSUES TO DISCUSS IN THE TREATMENT OF ACTIVITY DISORDER

• Overactivity of mind or body
• Body image
• Overcontrol of the body
• Disconnection from the body
• Body care and self-care
• Black-and-white thinking
• Unrealistic expectations
• Tension tolerance
• Communicating feelings
• Ruminations
• The meaning of rest
• Intimacy and separateness

The following section discusses a problem that is the polar opposite of too much activity exercise resistance. "Exercise resistance" is a fairly new term used to describe an intense reluctance to exercise, particularly seen in women.

Eating Disorders: Exercise Resistance in Women

by Francie White, M.S., R.D.

Just as binge eating disorder lies at the opposite end of the disordered eating spectrum from anorexia nervosa, exercise resistance is an activity disorder at the opposite end of the spectrum from addictive or compulsive exercise. As a dietitian specializing in eating disorders, I have noticed a common phenomenon in women with emotional overeating patterns, many of whom qualify as having binge eating disorder.

These women often suffer from entrenched inactivity patterns that are resistant to intervention or treatment. Many professionals assume that inactivity is due to factors such as a harried lifestyle, industrialization, laziness, and, in overweight individuals, the discouraging factor of physical difficulty or discomfort in moving. Behavior modification counseling programs, use of specialized personal trainers, and other types of motivational strategies to encourage a physically active lifestyle seem to be ineffective.

Over a three-year period, beginning in 1993, I began exploring what I call "exercise resistance" in a binge eating disordered population of six groups of ten to twenty women each. The following information is what emerged from studying these groups.

For many women with a history of body image problems, moderate to severe overeating histories, and/or a history of repeated attempts at weight loss, exercise resistance is a common syndrome that requires specialized treatment. Remaining inactive or physically passive appears to be an important aspect of the psychological defense system within the eating disorder itself, providing a balance of sorts from the psychological discomfort that accompanies exercising. This psychological discomfort varies from moderate to severe anxiety and is related to a profound sense of physical and emotional vulnerability.

Underactivity or physical passivity appears to offer a sense of control over body and feelings, just as disordered eating and over-exercise do. Exercise resistance may simply be another component in the menu of options from which men and women find themselves suffering in this time of epidemic eating and body image problems. If we are to begin to look at exercise resistance as a separate syndrome worthy of specialized understanding and treatment, here are some factors to consider.

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WHAT DIFFERENTIATES THE EXERCISE RESISTANT INDIVIDUAL FROM SOMEONE WITH SIMPLE LOW MOTIVATION OR POOR EXERCISE HABITS?

• The individual strongly resists any suggestion to become more physically active (barring any physical impairments and given several workable options).
• The individual reacts with anger, resentment, or anxiety to any suggestion to become more physically active.
• The individual describes experiencing moderate to severe anxiety during physical activity.

RISK FACTORS FOR DEVELOPING EXERCISE RESISTANCE

• A history of sexual abuse of any kind at any age.
• A history of three or more weight loss diets.
• Exercise used as a component of a weight loss regimen.
• A larger body size as a boundary or defense against unwanted sexual attention or sexual intimacy (be it conscious or unconscious).
• Parents who forced or overencouraged exercise, especially if the exercise was to compensate for perceived, or actual, overweight in the child.
• Early puberty or development of large breasts and/or early significant weight gain.

THE MEANING OF EXERCISE RESISTANCE

To better understand exercise resistance, we can borrow from our understanding of how weight loss diets have affected eating behavior. We know that weight loss diets are a key aspect in the historical mistreatment of overweight individuals, in many cases actually contributing to binge eating, which increases over time. Responses from the women surveyed support the view that exercise resistance may be an unexpected, unconscious backlash against the current cultural emphasis on slimness and the overfocus on the symptom; for example, the weight, instead of the inner psychodynamic issues.

QUESTIONS TO ASK THE INDIVIDUAL WITH EXERCISE RESISTANCE

• What feelings and associations emerge for you at hearing the term exercise? Why?
• When did being physically active change for you from "playing" as a child to "exercise"? When did it shift from something natural, an activity you did spontaneously (for example, from an internal drive), to something you felt you should do?
• Has physical activity ever been something that you did to control your weight? If so, how was that for you, and how has it affected your motivation to exercise?
• How did your exercise attitudes change during and after puberty?
• Does being physically active relate in any way to your sexuality? If so, how?

A theme ran through the comments of the women studied that echoes the information in chapter 4, "Sociocultural Influences on Eating, Weight, and Shape." Most of the women expressed that they felt extremely degraded and vulnerable by their direct experiences of being encouraged to exercise as a means to achieve an acceptable body. Instead of being encouraged to exercise for fun, exercise for these women was connected to body image, or the pursuit of an acceptable body.

Many of the women's stories included experiences of deep humiliation, public or otherwise, at being overweight and unable to achieve this illusive standard. Other women actually acquired a lean, thinner body and experienced unwanted sexual objectification by peers and adults. In a significant number of the women, rapes and other sexual abuse occurred after weight loss, and, for many, sexual abuse was connected to the onset of exercise resistance and binge eating.

Many women are confused as they experience the desire to be thinner while at the same time feeling anger and resentment at what they have been told they have to do to achieve it, for example, exercise. For some, exercise resistance and weight gain may be symbolic boundaries, expressing a rebellious refusal to patronize a system in which the playing field for women is not about sports, or even achievement, but about sexual attractiveness to men"We'll play, you pose." This system is one in which women and men equally participate and perpetuate. Women objectify one another and themselves right along with men.

The above discussion of exercise resistance by Francie White was written specifically for inclusion in this book. It is important to understand this area as another disorder on the continuum of those being discussed. The understanding and treatment of exercise resistance are similar to that of eating disorders in that the therapist must impart an empathy for the need for the behaviors instead of trying to take them away.

When working with an exercise resistant individual, one must explore and resolve the source of the resistance, such as underlying anxiety, resentment, or anger. The goal of treatment is that the individual will be able to become physically active by choice, not coercion. It is important to begin by validating the resistance and even in some cases prescribing it, making statements such as:

• It is important that you can choose to not exercise.
• Resisting exercise serves a valuable function for you.
• Continuing not to exercise is one way for you to keep saying "no."

By making these comments, the therapist helps validate the need for the resistance and eliminates the obvious conflict.

It is important to clarify that the issue of addressing exercise resistance is to help individuals who are compelled to "not exercise" just as we try to help others who are compelled to do so, both of which leave the behavior out of the realm of choice. Little attention has been paid to exercise resistance, but it is clear that those who have it, like those with exercise obsession or disordered eating, appear to be in a love-hate relationship with their bodies; derive inner psychological or adaptive functions from their behavior; and are involved in a struggle not just with food or exercise but with the self.

For an examination of the struggle with self and other dynamics that result in eating disorders, the next three chapters will deal with the main areas in which the causes of eating disorders are understood, with a chapter devoted to each of the following:

SOCIOCULTURAL

A look at the cultural preference for thinness, and the current epidemic of body dissatisfaction and dieting, with an emphasis not only on weight loss but also on the ability to control one's body as a means of gaining approval, acceptance, and self-esteem.

PSYCHOLOGICAL

The exploration of underlying psychological problems, developmental deficits, and traumatic experiences such as sexual abuse, which contribute to the development of disordered eating or exercise behaviors as coping mechanisms or adaptive functions.

BIOLOGICAL

A review of the current information available on whether or not there is a genetic predisposition or biological status that is at least partly responsible for the development of an eating or activity disorder.

next: Overview of Eating Disorders in Children
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Dear Dr. Stanton Peele:

Thank you for providing information on your web site that is thoughtful, provocative and informative.

Mine is a question that deals with personal freedom and MJ use and relationships. I married an inmate who when he came home after being released began to smoke MJ regularly. I was a bit shocked by his smoking since he never mentioned to me during the time we corresponded and visited regularly that he enjoyed MJ and that he planned to resume smoking it upon his release. (He was not placed under probation or parole because the PO wanted to "give him a break.")

However, his smoking MJ has caused me a lot of personal difficulty since I feel he smokes in an irresponsible manner (before going to work as a self-employed handyman, during our hiking in a public park, in his car while driving alone). I smoke neither tobacco nor MJ. I consider myself a light drinker. I don't like my husband's smoking MJ because I think that it creates a division between us and, more important, I think that it stunts his growth as an individual living a meaningful and responsible life.

I will be frank with you about my resentment over learning that he enjoyed smoking MJ after he came home from prison. He says, in his defense, that smoking MJ in California is not a felony (so he won't be facing 3 strike sentencing), that he works to contribute to the household expenses, and that he comes home at night, it relaxes him, and that for these reasons, I should not be concerned or upset.

I am, and that worries me. I would be grateful if you would provide me with some insight on the difficulty I experience over my husband's smoking MJ. I have thought of bartering with him. He would like me to get up earlier in the mornings because he's a morning person and I'm not by nature. However, I would gladly get up earlier if he would curtail his smoking or quit altogether. Please advise. I considered leaving the marriage over this. Thank you.

Sincerely,
A Wife

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Dear Wife:

You married an inmate? I guess you're finding out that even when they are not committing felonies, some people continue to act in consistently antisocial ways. This is important for understanding substance abuse and addiction. That he would not even mention he was a pot head to you — "didn't think it was relevant" — seems to show that he has a different value system than you do — but perhaps his prison time might also have told you that. I mean, littering is not a felony, but could you marry a litterer?

He does have a point — if mj relaxes him at home at night, perhaps it isn't society's business — but it is yours (it isn't illegal to drink alcohol, but you wouldn't want to marry someone who got drunk every night). Yes, I think bartering is worth attempting. What are you going to ask for exactly? No public mj smoking? Not smoking every night? Not smoking at all? I'm interested to know how he reacts.

Yours,
Stanton

next: John Allen of the NIAAA's Response to Stanton Peele's Article on Project MATCH in The Sciences
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To learn more about this controversy, read Caught in the Net, the first recovery book about on-line behavior and addictive use of the Internet.

While many believe the term addiction should be applied only to cases involving the ingestion of a drug, many researchers have previously applied this same term to high-risk sexual behaviors, excessive television-viewing, compulsive gambling, computer overuse, and overeating without such controversy. Mental health professionals do not agree on what constitutes an "addiction."

The common argument is that we can be addicted only to physical substances to which we have a chemical response in our bodies. If our bodies our hooked, we're hooked. Well, recent scientific evidence suggests that it may be possible to experience habit-forming chemical reactions to behavior as well as substances. Scientists studying the effect of addictions on the brain have focused new attention on dopamine, a substance of the brain associated with pleasure and elation. Scientists believe that levels of dopamine may rise not only from taking alcohol or drugs, but from gambling, eating chocolate, or even from a hug or word of praise. And when something makes our dopamine level rise, we naturally want more of it. Other studies indicate that as our brain reacts to familiar stimuli it can alter our behavior without our ever really knowing it, which may explain our tendency to excessively repeat addictive patterns. Therefore, linking the term "addiction" solely to drugs creates an artificial distinction that strips the usage of the term for a similar condition when drugs are not involved. Ultimately, it is unclear whether physiologic reasons are responsible for all addictive behaviors, rendering the debate between substance-based and behavior-based addictions meaningless.

Another significant issue is that unlike chemical dependency, the Internet offers several direct benefits as a technological advancement in our society and not a device to be criticized as "addictive." The Internet allows a user a range of practical applications such as the ability to conduct research, to perform business transactions, to access international libraries, or to make vacation plans. Furthermore, several books have been written which outline the psychological as well as functional benefits of Internet use in our daily lives such as Howard Rheingold's book, The Virtual Community and Sherry Turkle's book, Life on the Screen. In comparison, substance dependence is not an integral aspect of our professional practice nor does it offer a direct benefit for its routine usage. Therefore, when one juxtaposes a term with such a negative connotation as "addiction" against a positive tool as the Internet, it is easy to understand why people will respond with criticism. However, even positive activities in life such as gambling, food, sex, or the Internet - can be considered an addiction when it causes significant life problems, or when a person loses self-control.

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Desiderada is an inspirational prose poem about attaining happiness in life.

"Go placidly amid the noise and the haste,

and remember what peace there may be in silence.

As far as possible, without surrender,

be on good terms with all persons.

Speak your truth quietly and clearly;

and listen to others, even the dull and ignorant;

They too have their story.

Avoid loud and aggressive persons;

they are vexatious to the spirit.

If you compare yourself with others,

you may become vain or bitter,

for always there will be greater and lesser persons than yourself.

Enjoy your achievements as well as your plans.

Keep interested in your own career, however humble;

It is a real possession in the changing fortunes of time.

Exercise caution in your business affairs,

for the world is full of trickery.

But let this not blind you to what virtue there is;

Many persons strive for high ideals,

and everywhere life is full of heroism.

---

 

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Be yourself. Especially do not feign affection.

Neither be cynical about love;

for in the face of all aridity and disenchantment

it is as perennial as the grass.

Take kindly the council of the years,

Gracefully surrendering the things of youth.

Nurture strength of spirit to shield you in sudden misfortune.

But do not distress yourself with dark imaginings.

Many fears are born of fatigue and loneliness.

Beyond a healthy discipline,

Be gentle with yourself.

You are a child of the universe no less than the trees and the stars;

you have a right to be here,

and whether or not it is clear to you,

no doubt the universe is unfolding as it should.

Therefore, be at peace with God,

Whatever you conceive Him to be.

And whatever your labors and aspirations,

in the noisy confusion of life,

keep peace in your soul.

With all its sham, drudgery, and broken dreams,

it is still a beautiful world.

Be cheerful.

Strive to be happy."

The author is Max Ehrmann, a poet and lawyer from Terre Haute, Indiana, who lived from 1872 to 1945.

next: Acoustic Expressions: Music for Relaxation Meditation and Massage

If I had to distil my quotidian existence in two pithy sentences, I would say: I love to be hated and I hate to be loved.

Hate is the complement of fear and I like being feared. It imbues me with an intoxicating sensation of omnipotence. I am veritably inebriated by the looks of horror or repulsion on people's faces. They know that I am capable of anything. Godlike, I am ruthless and devoid of scruples, capricious and unfathomable, emotion-less and asexual, omniscient, omnipotent and omni-present, a plague, a devastation, an inescapable verdict. I nurture my ill-repute, stoking it and fanning the flames of gossip. It is an enduring asset.

Hate and fear are sure generators of attention. It is all about narcissistic supply, of course - the drug which we, the narcissists consume and which consumes us in return. So, attack sadistically authority figures, institutions, my hosts and I make sure they know about my eruptions.

I purvey only the truth and nothing but the truth - but I tell it bluntly told in an orgy of evocative baroque English.

The blind rage that this induces in the targets of my vitriolic diatribes provokes in me a surge of satisfaction and inner tranquillity not obtainable by any other means. I like to think about their pain, of course - but that is the lesser part of the equation

It is my horrid future and inescapable punishment that carries the irresistible appeal. Like some strain of alien virus, it infects my better judgement and I succumb.

In general, my weapon is the truth and human propensity to avoid it. In tactless breaching of every etiquette, I chastise and berate and snub and offer vitriolic opprobrium. A self-proclaimed Jeremiah, I hector and harangue from my many self-made pulpits. I understand the prophets. I understand Torquemada.

I bask in the incomparable pleasure of being RIGHT. I derive my grandiose superiority from the contrast between my righteousness and the humanness of others.

But it is not that simple. It never is with narcissists. Fostering public revolt and the inevitable ensuing social sanctions fulfils two other psychodynamic goals.

The first one I alluded to. It is the burning desire - nay, NEED - to be punished.

In the grotesque mind of the narcissist, his punishment is equally his vindication.

By being permanently on trial, the narcissist claims high moral ground and the position of the martyr: misunderstood, discriminated against, unjustly roughed, outcast by his very towering genius or other outstanding qualities. To conform to the cultural stereotype of the "tormented artist" - the narcissist provokes his own suffering. He is thus validated.

His grandiose fantasies acquire a modicum of substance. "If I were not so special - they wouldn't have persecuted me so".

The persecution of the narcissist IS his uniqueness. He must be different, for better or for worse. The streak of paranoia embedded in him, makes the outcome inevitable. He is in constant conflict with lesser beings: his spouse, his shrink, his boss, his colleagues. Forced to stoop to their intellectual level, the narcissist feels like Gulliver: a giant strapped by Lilliputians. His life is a constant struggle against the self-contented mediocrity of his surroundings. This is his fate which he accepts, though never stoically. It is a calling, a mission and a recurrence in his stormy life.

Deeper still, the narcissist has an image of himself as a worthless, bad and dysfunctional extension of others. In constant need of narcissistic supply, he feels humiliated. The contrast between his cosmic fantasies and the reality of his dependence, neediness and, often, failure (the "Grandiosity Gap") is an emotionally harrowing experience. It is a constant background noise of devilish, demeaning laughter. The voices say: "you are a fraud", "you are a zero", "you deserve nothing", "if only they knew how worthless you are".

The narcissist attempts to silence these tormenting voices not by fighting them but by agreeing with them. Unconsciously - sometimes consciously - he says to them: "I do agree with you. I am bad and worthless and deserving of the most severe punishment for my rotten character, bad habits, addiction and the constant fraud that is my life. I will go out and seek my doom. Now that I have complied - will you leave me be? Will you leave me alone"?

Of course, they never do.

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next: Grandiosity Deconstructed

When deprived of narcissistic supply - primary AND secondary - I feel annulled. It is a strange sensation, I am not sure it can be described.

Words, after all, do exist. But it is very much like being hollowed out, mentally disemboweled or watching oneself die. It is a cosmic evaporation, disintegrating into molecules of terrified anguish, helplessly and inexorably.

I lived through this twice and I would do anything not to go through it again. It is by far the most nightmarish experience I ever had in a rather febrile life.

I want to tell you now what happens to narcissists when deprived of narcissistic supply of any kind (secondary or primary). Perhaps it will make it easier for you to understand why the narcissist pursues narcissistic supply so fervently, so relentlessly and so ruthlessly. Without narcissistic supply - the narcissist crumbles, he disintegrates like the zombies or the vampires in horror movies. It is terrifying and the narcissist will do anything to avoid it. Think about the narcissist as a drug addict. His withdrawal symptoms are identical: delusions, physiological effects, irritability, emotional liability.

I want to tell you now about the two times in my life that I faced an utter absence of narcissistic supply and what happened to me as a result.

The first time was after Nomi abandoned me as I was in jail, deprived of all means of obtaining narcissistic supply and subject to the dehumanizing existence of a brutal penal colony. I reacted by retreating into a life-threatening dysphoria.

The second time was even more frightening.

I found myself in Russia in the throes of its worst economic crisis ever. I was a fugitive, having escaped the displeasure of a nasty regime I dared criticize and attack openly. Gaining access to sources of narcissistic supply was a tedious and narcissistically injurious process and my girlfriend was far away, in Macedonia. I lived in a decrepit apartment, with no hot water, with furniture in wooden death and tried to get accustomed to the brutish nastiness of everyday life there. I had no narcissistic supply of any kind - and this lasted for months. All my frantic efforts to generate supply - failed.

At the beginning it was a mere thought - following an exceedingly stormy night which I spent reading about Jack the Ripper. I imagined a decomposing body of a young woman emerging from the rusty bathroom (its creaking door half-hidden from where I slept). She leaned casually against the doorframe and said: "So, you finally came". Gradually, this gruesome image obsessed me to the point of terror. I was reduced to scribbling crosses on all doors together with special mantras I invented. At last, I could not stay there any longer and I moved to live for a few days with my client, a jolly, young and entrepreneurial Macedonian. His interpretation was that I was simply too lonely.

He couldn't understand why I was so uninterested in the ravishing girls that worked for him. He could not fathom my behaviour - reading and writing 16 hours a day, day in and day out, without a break.

But I knew better. I knew that my decomposing apparition was a manifestation of a psychotic break, the zombie of my disorder, my self-destructiveness embodied and my virulent self-hatred projected. I knew that "she" was as real an enemy as any I have ever come across. Narcissists often experience brief psychotic episodes when they are disassembled - either in therapy or following a life-crisis accompanied by a major narcissistic injury.

Psychotic episodes may be closely allied to another feature of narcissism: magical thinking. Narcissists are like children in this sense. I, for instance, fully believe in two things: that whatever happens - I will prevail and that good things will happen to me. It is not a belief, really.

There is no cognitive component in it. I just KNOW it, the same way I know gravity - in a direct and immediate and secure way.

I believe that, no matter what I do, I will always be forgiven, I will always prevail and triumph, I will always land safely on all my fours. I, therefore, am fearless in a manner perceived by others to be both admirable and insane. I attribute to myself divine and cosmic immunity - I cloak myself in it, it renders me invisible to my enemies and to the powers of evil. It is a childish phantasmagoria - but to me it is very real.

The second thing I know with religious certainty is that good things will happen to me. Good things always have, I was never disproved, on the very contrary - my belief only grows stronger as I grow older. With equal certitude, I know that I will squander my good fortune time and again in a bedeviled effort to defeat myself and to vindicate my mother and her transubstantiations, all other authority figures. She - and other role models that substituted for her in later life - insisted with a vengeance that I was corrupt and vain and empty. My life is a continuous effort to prove them right.

So, no matter what serendipity, what lucky circumstance, what blessing I shall receive - I will always strive with blind fury to deflect them, to deform, to ruin. And being the talented person that I am - I will succeed spectacularly.

I have lived in fairy tales come true all my life. I was adopted by a billionaire, an admiring student of mine became Minister of Finance and summoned me to his side, I was given millions to invest and have been the subject of many other miracles - but I was and am intent on bringing myself to biblical destitution and devastation.

Perhaps in this - in the belief that I have the omnipotence to conspire against a universe that constantly smiles upon me - lies the real magic of my thinking. The day I stop resisting my endowments and my good fortune is the day I die.

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next: The Music of My Emotions

I feel sad only when I listen to music. My sadness is tinged with the decomposing sweetness of my childhood. So, sometimes, I sing or think about music and it makes me unbearably sad. I know that somewhere inside me there are whole valleys of melancholy, oceans of pain but they remain untapped because I want to live. I cannot listen to music - any music - for more than a few minutes. It is too dangerous, I cannot breathe.

But this is the exception. Otherwise, my emotional life is colourless and eventless, as rigidly blind as my disorder, as dead as me. Oh, I feel rage and hurt and inordinate humiliation and fear. These are very dominant, prevalent and recurrent hues in the canvass of my daily existence. But there is nothing except these atavistic gut reactions. There is nothing else - at least not that I am aware of.

Whatever it is that I experience as emotions - I experience in reaction to slights and injuries, real or imagined. My emotions are all reactive, not active. I feel insulted - I sulk. I feel devalued - I rage. I feel ignored - I pout. I feel humiliated - I lash out. I feel threatened - I fear. I feel adored - I bask in glory. I am virulently envious of one and all.

I can appreciate beauty but in a cerebral, cold and "mathematical" way. I have no sex drive I can think of. My emotional landscape is dim and grey, as though observed through thick mist in a particularly dreary day.

I can intelligently discuss other emotions, which I never experienced - like empathy, or love - because I make it a point to read a lot and to correspond with people who claim to experience them. Thus, I gradually formed working hypotheses as to what people feel. It is pointless to try to really understand - but at least I can better predict their behaviour than in the absence of such models.

I am not envious of people who feel. I disdain feelings and emotional people because I think that they are weak and vulnerable and I deride human weaknesses and vulnerabilities. Such derision makes me feel superior and is probably the ossified remains of a defense mechanism gone berserk. But, there it is, this is I and there is nothing I can do about it.

To all of you who talk about change - there is nothing I can do about myself. And there is nothing you can do about yourself. And there is nothing anyone can do for you, either. Psychotherapy and medications are concerned with behaviour modification - not with healing. They are concerned with proper adaptation because maladaptation is socially costly. Society defends itself against misfits by lying to them. The lie is that change and healing are possible. They are not. You are what you are. Period. Go live with it.

So, here I am. An emotional hunchback, a fossil, a human caught in amber, observing my environment with dead eyes of calcium. We shall never meet amicably because I am a predator and you are the prey. Because I do not know what it is like to be you and I do not particularly care to know. Because my disorder is as essential to me as your feelings are to you. My normal state is my very illness. I look like you, I walk the walk and talk the talk and I - and my ilk - deceive you magnificently. Not out of the cold viciousness of our hearts - but because that is the way we are.

I have emotions and they are buried in a pit down below. All of my emotions are acidulously negative, they are vitriol, the "not for internal consumption" type. I cannot feel anything, because if I open the floodgates of this cesspool of my psyche, I will drown.

And I will carry you with me.

And all the love in this world, and all the crusading women who think that they can "fix" me by doling out their saccharine compassion and revolting "understanding" and all the support and the holding environments and the textbooks - cannot change one iota in this maddening, self-imposed verdict meted out by the most insanely, obtusely, sadistically harsh judge:

By me.

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next: Narcissist: I Love to be Hated, Hate to be Loved

MUST HAVE books for people with depression, information for sufferers, family and friends

 

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Undoing Depression: What Therapy Doesn't Teach You and Medication Can't Give You
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Since the early 1970s, research into the origins of eating disorders in young women has spotlighted the mother-daughter relationship. Some researchers have suggested that mothers "model" weight concerns for their daughters, although findings have been inconsistent when testing this hypothesis. An alternative conceptualization focuses on more specific, interactive processes between mother and daughter that may contribute to (or mitigate against) the development of these concerns, and could apply to dyads for whom modeling may be a factor as well as for those for whom it is not.

Jane Ogden and Jo Steward, from the United Medical and Dental Schools of Guys and St. Thomas' in London, evaluated 30 mother-daughter dyads with regard to their degree of concordance about weight concerns (a reflection of the modeling hypothesis) as well as the role such dynamics as enmeshment, projection, autonomy, beliefs about mother's role in the relationship, and intimacy play as predictors of weight concerns and body dissatisfaction in the daughters. The daughters in this study were between the ages of 16 and 19, and the mothers between the ages of 41 and 57. They were primarily white and self-described as upper middle class.

Findings appear in the July 2000 issue of the International Journal of Eating Disorders.

Beliefs About Autonomy and Boundaries Predict Eating and Weight Concerns

Within this sample, while there was a similarity in weight and body mass index between the young women and their mothers, mothers and daughters did not share the same views about dieting or body satisfaction. In this study, therefore, the modeling hypothesis was not supported.

There was, however, support for the interactive hypothesis. In particular, daughters were more likely to be dieting when they had mothers who reported feeling less in control of the daughter's activities as well as if both mother and daughter saw it as important that their relationship lack boundaries (i.e., they were enmeshed). Daughters were more likely to be dissatisfied with their bodies when their mothers reported feeling both less in control of the daughter's activities and feeling the daughter did not have a right to her own autonomy as well as if the mother saw it as important that their relationship lack boundaries.

This study suggests that there is far greater complexity to the development of weight concerns in young women than simple modeling of thoughts and behaviors by their mothers. Clinicians who work with adolescents may want to pay specific attention to relationship dynamics between mother and daughter, particularly aspects of control and enmeshment that may be predictive of the development of eating and body shape concerns if not the development of an actual eating disorder.

Source: Ogden, J., & Steward, J. (2000). The role of the mother-daughter relationship in explaining weight concern. International Journal of Eating Disorders, 28(1), 78-83.

next: How Coaches Inspire Eating Disorders
~ eating disorders library
~ all articles on eating disorders

Ten ways to help yourself deal with an eating disorder

1. Buy a self-help book. Research has proved that self-help books can be enormously effective.
2. Begin to keep a diary - write down feelings. Make your diary personal to you - be your own confidante and friend in whom you confide your thoughts. Scribble, stick in photos, draw pictures - there are no rules about how you have to use the space.
3. Begin to be in touch with the feelings and thoughts around the binge eating. Begin to understand your underlying emotional issues.
4. Ask yourself what is it that you really want instead of food - is it a response to the worry of work? Do you really want a hug, a chat with a friend?
5. Start nurturing and pampering yourself. Set aside time in the day for your own relaxation and leisure periods. Prioritise your needs.
6. Dare to say yes to yourself instead of no. Learn to accept the way you are and begin to appreciate and love yourself.
7. Do not overly criticize or judge yourself harshly. Over zealous self-criticism will drive the compulsion of the eating disorder.
8. Draw a family tree to include all friends and all those living or dead. Write down your family history noting dramatic or eventful periods of change.
9. See if there are emerging patterns of behaviour. Look at the way you relate to others. Do you have equal give-and-take in relationships? If not look at books on assertiveness or join an assertion group.
10. Be gentle on yourself. Accept the way you are. Your eating disorder has enabled you to cope with difficult circumstances. See if you can come up with other coping strategies which are less harmful.

Books

Getting Better Bite by Bite - A survival kit for sufferers of bulimia nervosa and binge eating disorders Treasure & Schmidt - Psychology Press

Eating your Heart Out Buckroyd - Optima

Anorexia Nervosa - A Guide For Sufferers and Their Families Palmer - Penguin

next: Eating Disorders Self-Help Tips
~ eating disorders library
~ all articles on eating disorders