Stress in pregnancy as a contributory biological cause.

I am working hard at keeping up Waif's calorie count - catching her "swaps". For instance, this morning she ate an apple (about 53cal) and said that was instead of her fruit juice (94 cal for her 200ml apple juice). It can be no coincidence that her swaps are always for a lower calorie option. I negotiated an extra cheese string to make up the difference.

Last night, I bought Waif a slice of cheesecake and found half of it back in the fridge. I told Waif she needed to finish it (it was only a single portion as sold by Kruger in the picture). She did so but sulked immensely and said that had she known she had to eat the whole thing, she would have had a (mini) kitkat. This is despite the fact that she prefers the taste of the cheesecake, so I conclude that she is still struggling to eat calories freely. I suspect that true recovery will not happen until she is not calorie obsessed and eats for joy and from hunger. Perhaps anorexics never manage to regain a love of food - texture, flavour and social binding :-(

Rats, I have just realised that Waif volunteering to catch a bus from school to her after school tennis means that she won't get her half hour at home to have a hot chocolate and some toast before she plays. Hmmmm...... I will text her and tell her to buy some snacks at the school tuck shop and HOPE that she eats them. I need to warn her that if she has not gained wait at her next weigh-in then tennis will have to cease :-( That would be a shame.

Meanwhile, I have been considering the biological factors that predispose children to anorexia: I wondered why, at the initial interview, the Maudsley team asked me about my pregnancy and birth experience with Waif. I now realise why they did that. I now know that stress in pregnancy is a predisposing factor.

At the time, I said that the pregnancy was trouble free - it was, it was very straightforward even if I knew early on that I would be induced 2 weeks before my due date as I am a small build and Waif was a big baby.

I didn't mention, which I now believe could be contributory, that I suffered a lot of stress in my pregnancy from unrelated causes: my husband suffered from acute pain one evening when I was heavily pregnant and I had to get him to hospital (which was arduous with a reluctant opinionated and tired 20 month old in tow, being pregnant and my husband being 6ft 4 and unable at that point to walk unaided. We spent about 15 minutes trying to even get down the stairs from our first floor flat. I too ended up being treated in casualty as I dramatically passed out on arrival. Worse than that, when H came round from his acute operation for testicular torsion he had largely lost the ability to speak.

He was discharged from hospital without this lack of speech being addressed - the doctor made a classic comment to me. He said: "your husband never told me about it" !!! (d'oh, he can't speak) and refused to deal saying that we should go home and see our GP. Mind you, the area around my husband's bed was splattered with old, dried blood (not his own) and I saw a nurse administer 2 doses of insulin at once to the lady in the next bed and then fake the chart to say that she had given them at 4 hourly intervals (she had obviously forgotten earlier). I cannot believe this did the lady in question any good at all, so I was happy to get my husband away.

The GP was flummoxed and recommended a neurological appointment. Our appointment came through as being in 6 months time as his case was "not urgent". "But how can my husband, a lawyer, work without being able to talk?" "That's not our problem and doesn't make it a medical emergency."

My husband was looking at resigning and we both feared a brain tumour.

Meanwhile, I was having maternity discussions with my own employer - I was working full time in those days as we had little money - who told me that I could only have the 3 weeks statutory leave and had to come straight back to work after the birth or else they would make my life very difficult. They also wanted me to pay rent for my work accommodation for which noone else (all men) paid because "my husband ought to be providing for me". I did not tell them about my husband's medical problems because I would fight such an assertion on feminist grounds alone and we were trying to keep it quiet as my husband was trying to still work (diverting his phone).

TO cut to the chase, I was under a lot of stress for a while that I was pregnant with Waif: facing the prospect of being moneyless and having a husband at home who needed nursing as he died (worse case scenario) and being unable to give up my job as the only source of money, even if it would only just cover the nursery/ nanny fees for the soon to be 2 under threes, leaving us no money for food or bills.

My readers will be pleased to know that I managed to arrange a private neurological appointment (the best 200 we have ever spent) to then meet a sympathetic neurologist who gave my husband an NHS mri scan when he realised we were not insured, and diagnosed a simple epileptic type disorder in my husband which is easily controlled through drugs. So ultimately we were fine. Indeed, we have gone on to become rich on his earnings. But whilst I was pregnant with Waif, there were without doubt worries and now I wonder if those contributed to Waif's vulnerability to this horrid Eating Disorder......

Stability.....

Well, the good news is that Waif hadn't lost any weight, but neither has she gained any in the last 2 weeks :-( In my view, it is just recently that Waif has stopped eating so well. Yesterday, for instance, she had asked me to bring a sandwich to her after school as we would miss tea, what with driving to the Maudsley. She wanted a jam sandwich but I brought along a tuna one (her usual favourite). She refused to eat it, saying that the reason was that she was saving it for supper (!). I suspect she read the packet and saw the 440 kcalories as I had chosen one with plenty of mayonnaise and not a calorie-counted vinaigrette version.

In view of her plateau, we have decided that Waif needs to eat MORE than is on her meal plan. She started this morning by having an extra piece of toast for breakfast as well as her usual jam sandwich and bowl of cereal. As ever, she managed to at breakfast whilst I was walking her older sister to the school bus-stop and before my husband was out of bed so I didn't actually see her eating. I need to ask her to eat with OD at 6.40am, or else wait until 7.20am for "second breakfast" - I take her to school at 8am. Alternatively, I need to ask my husband to get out of bed at 7.10am and supervise the 7.10am shift.

I have been truly impressed with H lately as he has made a significant effort to get to all Waif's Maudsley appointments and this makes a difference - I am especially convinced of this having listened yesterday to the importance of comments made by fathers as being very triggering or, conversely, helpful.

We talked about how Waif would not be allowed her orthodontic braces, for which she is nearly ready, needing just one more deciduous tooth to be shed, until she is within the normal weight range. The psych explained that it is tricky to gain weight whilst wearing braces. I can vouch for that. Let's hope that is an added incentive for Waif.

Eating Disorders research unit lecture

I was intending to go to this lecture in January but was beaten back by snow in London bringing it to a standstill. You can listen to the audio file.

http://podcast.streamingwizard.com/gresham/MP3Audio/2010/Jan10/Eating_disorders.mp3

Or you can watch it (the pictures are good) here:

http://www.gresham.ac.uk/event.asp?PageId=45&EventId=973

It traces the history of the disease from religious fasting to bulimia identified in the 70's, increasing rapidly in the 90's, and on to the modern disorder of obesity. The second part of the lecture is a personal history.

0.5 - 2 % have AN

2-4% have bullimia

Larger numbers, up to 10% of young women, suffer from EDNOS - eating disorder not otherwise specified (like Waif).

There is a 9:1 ratio of EDs in towns and cities compared with in a rural environment, and also Westernised countries. We are living in London which is not a good start.

There are certain biological factors that are correlated with an increased likelihood of developing an ED:

- stress in pregnancy and/or birth

- having a strong relationship with one's father is very protective

- having a father who approves of thinness and/or who teases about weight is particularly toxic

- the attitude of the mother was commonly thought to be important but the research has in fact indicated that the key relationship is with the father, although insecure attachments of the sufferers and perhaps of their mothers too can be a factor.

- EDs in the family increase risk

There are then triggers:

- the media's obsession with Size Zero and airbrushing images

- the initial praise gained by the sufferer when she loses weight

- stress

Other factors tend to sustain the ED after it has commenced, the main one being the effect of starvation on the brain. This means that the sufferer becomes impaired at emotional recognition and regulation - she may have temper tantrums, for instance. I found this interesting as OD gets fed up with Waif's unreasonableness at times and perhaps, after listening to this lecture, she will have more understanding. The upshot of the inability to understand emotions normally is that the sufferer can lose friends and become socially isolated, leaving ED as her "only friend" (snort).

Another cognitive effect of starvation on the brain is that on the ability to think flexibly and to step back and see the bigger picture is inhibited. This too can hinder recovery.

Treatment should focus on these barriers to recovery.

One interesting study showed that rats, when starved and then given unlimited access to palatable food on, say, Mondays and Wednesdays, compulsively over eat. Worryingly, they also show a change in their brains rendering them more "addictive" generally. I worry about Waif drinking/ smoking to excess when she is older as she is immoderate in all she does at the moment. Nothing is half hearted (unlike the rest of us, she never gives up half way through a task).

Gresham College is a wonderful institution.

Mealtimes and Milestones

Now 16, Constance was diagnosed with anorexia in 2007 at 14 years old, and wrotea diary which is now published.

Here is an extract.

I may give this to Waif to read. The thought of being fed by a tube is horrendous.

Eating Disorders Awareness week starts today.

Waif has her Maudsley appointment after school. I will be surprised (and delighted) if she has put on much weight. My best guess is 200 grammes. Just recently, she has always eaten "just before" I get to the kitchen.......like this morning - at 7.10 I take Older Daughter to the bus stop and am back at 7.30 to do breakfast for Waif but she has "just eaten" :-( I so hope she really has. She has asked me to bring a jam sandwich to school when I pick her up for eating just before her appointment. Is this a good thing or a last minute panic? At least I don't think Waif has lost weight - she still looks a little healthier than 4 weeks ago when she looked dreadful.

I am reassured to find this answer posted at wikianswer when Waif asked her questions - there is some sensible information on the damaging effects of anorexia.

I am also not clear whether if the history shows a search for, say "anorexia tips" but no following page, whether that means that Waif never in fact clicked through. I hope so.

I have had a more thorough look and it is also only last night that Waif has made such searches. Not earlier in the week. Hmmmm.....I was out last night with Older Daughter. My husband was home and his sister (the one who used to be extraordinarily thin and is even now, at 39 years old, very very careful about calories). I wonder if between them, those were the triggers. I am going to phone my H at work and ask him about last night and whether his sister ate properly or whether she said her usual "oh, I just had a really big lunch/ supper/ meal on the plane" and ate very little.

I am glad that Waif has an appointment at the Maudsley on Monday coming as it will become clear whether or not she has managed to maintain a steady weight gain.....

New Worries

Sigh, it was seeming to all go so well. Waif is looking healthier and healthier.

It has admittedly been a little odd recently because she has been rushing to eat before I am in the kitchen, and so eating a lot whilst I have not been around: "Mummy, I have already had my toast and cereal" and there will be crusts on the plate and a bowl with the dregs of milk in it.

But I have still, on the whole, witnessed a lot of calories eaten every day even if Waif has also oddly been eating all her evening meals at once: eating her main meal and immediately afterwards having her late night hot chocolate and biscuit, insisting that this means she won't forget later and that if she does eat later it will be a bonus.

This morning, she has gone out to a lecture on maths (yes, she is that kind of child) and left her laptop on and open in her bedroom. I thought I would check her internet history hoping to find that she is no longer obsessed by calories.

The latest pages checked were the Space and Time cafe (this is the cafe at the Royal Institution where she is headed today). That could be a good thing. Perhaps she is planning her snacks.

Then a check of all calories at Pret a Manger (I had told the children to buy lunch on their way home). Ok. Fine.

Then below that a check of the calories in mushroom taglietelle (yesterday's lunch). Jury out.

And then, horror, I saw that she had been looking at sites called things like "tips for anorexics" "what do anorexics eat?" and "how to eat a low calorie breakfast that looks high calorie".

This is not good.

Then I scrolled down and saw that she had been searching for "casual fun for women" and "naughty schoolgirl" and "naughty santa outfit".

Good grief, it is possible for anyone to look at a page in error and to click through, fascinated yet horrified. I have not actually looked at any of the pages Waif has been on. Perhaps I should.

I really don't know whether to tell Waif what I have seen and to confiscate her laptop. I am worried that if I simply say she will have it confiscated if she looks at those sites again will just drive her to do it more secretively - within Google Chrome incognito for instance.

The internet is such a powerful tool and can be used for good or bad.

I so do not want her accessing poisonous pro-ana sites. Perhaps I should talk to her about them and about how a whole community can become deluded and dangerous, and how she must stay away if she is to have a full and happy, healthy life.

I wonder what has triggered this.

I am very upset and any tips on how I should tackle this would be welcome.

Metrics and Celebrations

Waif is now 39.4kg!!! :-) She has put on weight!! :-) :-) I am soooooooooo pleased. I know this is not the end, or even the beginning of the end, but perhaps it is the beginning of the beginning.

At 160cm, Waif now has a BMI of 15.4. Whilst this is still far too low, it is over 15.

Best of all, Waif seemed genuinely pleased at her progress.

Now, we have to build on our progress. Perhaps next time, Waif will have put on another kg and even surpassed the 40kg mark.

Maudsley Hospital again

Today is Monday so we are back to the Maudsley this afternoon.

I am very optimistic that Waif has put on some weight. Not much, mark you, but some. She looks less ill to me, and less startlingly skeletal. I hope it is not just that I am getting used to her thinness.

This is no magic cure: Waif is still ambivalent about weight gain - she still won't eat a morsel more than is on her menu list and always opts for the smallest/ least calorific option put before her even if I know she prefers the alternative. But as long as she is making progress I will be happy that she is reducing the chances of permanent damage to her body.

At some point we will have to tell her psychiatrist about Waif's worries being alone at home, andsleeping in her own bed at night. At 13 years old I fell that she should feel more secure in her own house.

Waif is not going in to school today. Older Daughter is not well and Waif thinks it will be "easier" for her not to go in. I am easy with that - the more Waif stays home, the more food I can supervise being eaten and in the end there is no point in her doing well in all her exams only, God forbid, to die of a heart attack at 23 or to find that she is unable to have a family if and when she wants one.

My husband has taken the day off work in order to come with us to the hospital, and Older Daughter might well come too so we would have a full house again. I am sure that the sessions are more helpful if we are all there together.

Cross country running part 3

The Maudsley Hospital phoned back yesterday (bless them). They said that Waif could run her race provided she ate an extra 1,000 calories. I told Waif that she had to eat an extra 1,000 calories before AND an extra 1,000 calories after.

Waif really seems to have done that :-) She set a new record for breakfast this morning - as well as her usual 2 pieces of toast (wholemeal, crusts off, no butter, smear of jam) and bowl of cereal (bran flakes), she had a hot chocolate, a rice pudding and an apple. How I would like to see that every day! It also turned out that the race was only 2km so I am pretty sure that she will have come to no harm and will have done less exercise than usual in total as she traded me yesterday afternoon's games lessons when she came home and rested instead (we watched Enchanted on Sky-plus together). The games lessons would have totalled an hour and a half whereas her run was probably about 15 minutes.

I discovered this morning why Waif was so keen to go - her friends from her old school were also competing :-) All in all, she had a good day even if it was 4 hours total in the coach (which is a good thing in my view as it involves sitting still). Oh, she was also pleased to come 39th out of 250 competitors. I told her that she could be a very good runner if she can build up her strength and put on some muscle (it's true). Hmmm.... she has now asked to go for tennis lessons every Friday night at the local club. I am okay with it as long as she is willing to take in extra calories in compensation and is putting on weight. I have told her that if she stops putting on weight then all sport will come to a complete halt. Getting to a healthy size has to be her utmost top priority - what's the point of being good at tennis if you might die of heart failure at 23? :-(

Meanwhile Older Daughter has announced that she wants to go to boarding school. I can see her point as it is all quite stressful at home. The only problem is that she has just missed out on all the deadlines for sixth form entry. As she is a very clever girl and likely to do extremely well in her GCSE's, I am confident we could find her a place somewhere but not, perhaps, the top boarding school of her choice.... I am writing begging letters. Her main focus needs to be on entry to med school coming up soon. I feel I have been neglecting her recently....

Karen Carpenter

http://atdpweb.soe.berkeley.edu/quest/Mind&Body/Carpenter.html

Cross country running part 2

Hmmmm...raceday is tomorrow. Waif still hasn't discovered how far the race is. As the psych was busy this week, Waif had no appointment yesterday so I do not know whether or not she has put on weight - on our home scales she comes in at 37.5kg which is no weight gain but our home scales may underweigh. My guess is that she HAS put on some weight; she has more of a healthy glow in her face, has lost the dark shadows under her eyes and her hands are warm. I would like to reward that.

Also, Waif is letting me pick her up from school at lunchtime today as the afternoon is one of PE, so she will have voluntarily foregone 1-2 hours of exercise today. She is hoping for a trade, no doubt, and has also promised to eat loads straight after. I may negotiate that she eats loads TODAY (carbohydrate loading) as well as something sugary immediately before the race and lots of protein after, and an okay from the Maudsley in terms of her not actually being in danger of damaging her heart. Mortified as Waif may be not to run, I cannot allow her to damage her body permanently.

I spoke to my husband about this issue yesterday. I suggested we should decide on a weight, say 40kg, above which she can race. My husband expressed the concern that if Waif put on weight then she might be carrying too much excess to be able to run a good time. Grrrrrrrr..... She would not be too heavy to race with a BMI of, say, 16!!!! Sigh, he gets it a bit because he agrees that she is too thin at the moment.