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Exposure and response prevention

Posted Apr 15 2010 8:52pm
I'm going to indulge my geeky side here briefly, as I stumbled across a research article about the use of exposure and response prevention for anorexia .

The International OCD Foundation describes exposure and response prevention as
The "Exposure" in ERP refers to confronting the thoughts, images, objects and situations that make a person with OCD anxious.

The "Response Prevention" in ERP refers to making a choice not to do a compulsive behavior after coming into contact with the things that make a person with OCD anxious.

This strategy may not sound right to most people. Those with OCD have probably confronted their obsessions many times and tried to stop themselves from doing their compulsive behavior, only to see their anxiety skyrocket. With ERP, a person has to make the commitment to not give in and do the compulsive behavior until they notice a drop in their anxiety. In fact, it is best if the person stays committed to not doing the compulsive behavior at all. The natural drop in anxiety that happens when you stay "exposed" and "prevent" the "response" is called habituation.

It's primarily used to treat people with OCD, but since there is an overlap in many of the symptoms of OCD and eating disorders--"The overlap between AN and anxiety disorders suggest a model of AN in which baseline anxiety features yield eating related fears, avoidance behaviors, and ritualized safety behaviors that promote the underweight state and the perpetuation of the disorder."--the authors thought that ERP, as it's commonly known (because if the psychotherapy community loves one thing more than couches, it's acronyms), might be helpful in relapse prevention. Their guess was right.

This blog post isn't about the study- I'm trying to stay committed to my pledge not to intellectualize my illness. But as I was in the bakery today, I was thinking about this study. Why? For one, I had lots to do and very few customers, which meant my mind was free to wander about. For another, I got offered a sample today, this time by the cheese people. I was offered a piece of queso manchego , and I took a teensy little piece. I didn't know if I would like it, and also that whole eating disorder thing I've been telling you about. The cheese lady asked me what I thought, and I nodded and said "Pretty good." And the cheese was. So the cheese lady said, "Here, have a bigger piece." I just about flipped the shit on that one--two pieces of cheese in one day?!?--but I also knew that my recovery depended on saying yes and so I did say yes and had the second piece of cheese.

Which is just about when I started freaking out. I had every imaginable thought running through my head, ranging from "Everyone is going to think I'm a PIG!" to worries about massive weight gain from a small piece of cheese. This is why I avoid samples, I thought, because it's so freaking stressful.

Once I calmed down a bit, I was able to talk myself off the ledge of oh-shit-I-ate-too-much and I got a wry chuckle out of how much exposure to my ED fears this job is giving me. And cue thoughts of the study I cited above.

Although I don't think an eating disorder is "about" control, I certainly would say that it's a major theme in many people's eating disorders, including mine. I did some exposure work with fear foods in the past, but that exposure was always on my terms. I made sure I was never in a situation in which I couldn't get out of eating. More than that, I did my damnedest to make sure that I wouldn't be in a situation in which I'd be offered food without my being aware of it (I fully expected to be offered hors d'ouerves at a cocktail party, or even a meeting over coffee, so I could "plan" or restrict accordingly if I couldn't get out of it). Even in the bakery, I still have control. No one is making me try things. I won't get sacked because I don't/won't/can't sample the eclairs or the cannoli. I could make up a dairy allergy, a wheat allergy, a calorie allergy to look less like a freak.* But I know that recovery means learning to live with offers of food without my fight or flight response kicking in.

So I said yes to the second (fairly sizable) slice of cheese.

Before you go patting me on the back too much, know that I had packed a string cheese with my dinner, and I substituted the queso manchego for the string cheese. If I didn't have an item that was quite so equivalent, I probably would have backed out. But I accepted the cheese and ate it and found that it was actually quite good- a lot like Parmesan but less crumbly and pungent. I didn't plan on having the cheese, I didn't know the exact calorie count, and I accepted a sample at the bakery--all of which are anxiety provoking things for me.

In ERP, the therapist usually asks you to create a hierarchy of anxiety-provoking tasks for you to accomplish, starting from the least anxiety-provoking to the most. And then you systematically begin exposing yourself to the items at the bottom of the heirarchy, and work your way to the top. Today's cheese incident was probably fairly low on the heirarchy- maybe not the lowest, but definitely not at the top.

And I ate the cheese. And I survived. I didn't restrict, I didn't purge. I am exhausted and frustrated (dude--it's cheese!), and I hate to think that this ERP party is just getting started, but I suppose it is what it is.

*"I'm allergic to food."
"So what do you eat, then?"
"Diet Coke, black coffee, and mustard."
Don't think I haven't seriously debated using this line! LOL
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