The Pain/ Depression Cycle: Is Your Pain Caused by Depression or Vice Versa?

By: Ryan Lawrence


Over the decades, medical professionals have begun to recognize that depression can have a significant physical impact on our bodies. Studies have shown that depressed people are more prone to suffering from physical ailments, such as heart problems and osteoporosis. That said, above all else, depression appears to be tightly linked to physical pain.

A Complex Relationship

Researchers know that pain and depression have a real but confusing relationship. Physicians often struggle to identify the source of certain physical ailments when they are combined with depression. Like the chicken and the egg, it's not always clear what is causing what. When depressed patients visit the doctor, they often complain of vague, insistent symptoms, such as abdominal pain, headaches, or musculoskeletal pain in the neck, joints and lower back.

This often leads physicians to test for all sorts of ailments before finally attributing the problem to depression. Many times, antidepressants and cognitive therapy help to resolve symptoms of vague, chronic pain. On the other hand, just as often, this treatment strategy proves ineffective, because it's actually focusing on a symptom rather than the source problem, itself.

When Pain Causes Depression

  Years ago, health professionals believed that people who suffered from both pain and depression experienced the former, because they were somehow denying an emotional disorder. Now, more and more experts believe that it's actually pain that makes people depressed in the first place.

According to Dr. Donna Blair, who treats people suffering from temporomandibular disorder, many of her patients have experienced improved mood once they received treatment for the source of their chronic pain.

"I see people whose teeth are worn down to a fraction of the length of what they used to be from years of grinding," she said. "They've been in pain for years, but didn't know that a problem in their jaw joint could have been the cause; and they're amazed at the increase in quality of life that they get when their teeth are restored and their bite is corrected."

An Endless Cycle

  Unfortunately, chronic pain and depression can promote one another. This is especially true when one or the other promotes sleeping difficulties. According to Blair, research has shown that insufficient sleep can promote both pain and depression, leading to a seemingly endless cycle that can send people into a downward spiral.

"Sleep is so critical to our well-being, and when we don't get enough of it, our bodies suffer," she said. "When you add pain to the mix, people have trouble sleeping and it sets a vicious cycle in motion. Depression is just part of what frequently happens in this cycle, but it's one of the signs and symptoms that people are more aware of. Things like increased risk of heart attack and stroke usually go unnoticed until it's too late."

Getting Help

Chronic pain has been proven to keep depressed people depressed, while robbing them of their ability to function in professional and social arenas. That said, when patients receive treatment, they tend to show significant improvement.

When seeking help, patients would be well-advised to seek counsel from physicians who are open to all potential causes, instead of those who are focused on purely physical or psychological catalysts.

Citations:

• Journal of American Medical Association depression study

Featured images:

•  License: Creative Commons image source 

Ryan Lawrence writes for Off-Topic Media. Thanks to Dr. Blair for contributing to this story. Dr. Blair treats migranes and other TMJ symptoms at her office in Fresno, California.

My family and I are in the process of moving and we only have a month to do it in, so forgive me if I seem a little scarce around here. I will be back full force as soon as we are settled in ;)

The Power of Words

Here are some phrases you never hear:

"I'm AIDS."

"I'm Lupus."

"I'm a bone fracture."

So why are there phrases like this?

"I'm bipolar."

"I'm schizophrenic."

"I'm crazy."

It may not seem like a big deal to everyone. The emphasis on certain words is interpreted in varying measures by each person, and the difference of being and having something may not even register to some. But. It does to me. I have a real pet peeve about phrases like "I'm bipolar". We hear it said like that everywhere. In movies. In the news. In conversations. It's even used to describe people who do not even have a diagnosis of bipolar disorder. If a person is in a bad mood or emotional, they are automatically penned "bipolar". Is this acceptable to you?

This is why I have a problem with it:

"I'm bipolar" suggests that your whole body is wrapped up in this word; it becomes the definition of everything about you. It owns you. You are a slave to society's views about your mental illness, and you're seemingly complacent about it. Stigma feeds off of you.

"I have bipolar disorder" tells a different story, and a more accurate one. You are an individual with many traits and characteristics. You may have a distinct birth mark, a knack for mathematics, a perfectly aligned set of teeth. Among all your visual and perceived traits, you have an illness-a flaw in your chemistry-and it affects you in certain ways. It can appear to take over your whole being at times and muddle the regular attributes of your personality. But you have it. It does not have you.  This particular aspect of your life can be treated, subdued, survived. It does not own you. Just like a broken bone, a part of you may be wounded, but you as a whole are not a broken person.

Remember this in your self-talk and when you are describing your illness to others. It will make a difference in how you perceive yourself, and it just might portray a more realistic image of mental illness to those around you. Words have a certain power to them, and you can choose to use uplifting ones or degrading ones. The words you choose will impact your entire view of life. Choose words that reflect your true self, and never let your illness define you.

Decisions, Decisions

It's amazing how freeing making a decision can be. I like dealing in absolutes. When everything is up in the air, when the winds can turn it this way or that, then my whole body feels the upheaval, and it resides in my brain and my bones, sucking out the will in me, until the issue is resolved. I am happy to say that my family and I have come to a decision about a situation that has been weighing heavily on each of us for a few weeks. Now, there's a lot of hard work ahead, and I will have to keep check on my mental health throughout it, but just knowing the next steps on the path has greatly diminished the stress and depression I have been experiencing as of late. There will always be uncertainties and bends in the road, but at least we have a plan in place now. What a relief!

I hope you all have a terrific weekend!

Your Life, and Why It Matters

It's hard to remember at times, but I really do love my life. Sometimes it can really suck (to say the least), but the good times make up for all the bad. It is always the simple things that mean the most, and the sweetest treasures often come along when we least expect it. It is because of this that there is always a reason to try, always a reason to give just a little bit more, and there is no excuse for not sharing all we have to offer with the world. One of my favorite quotes from Martin Luther King, Jr. is  "If you can't fly, then run. If you can't run, then walk. If you can't walk, then crawl. But whatever you do, keep moving." I know sometimes it seems like there is no point in trying, especially when living with a mental illness or disability. It is hard to find a balance of accepting limitations and being dictated by them. I don't believe any of us are wasted space. You don't have to believe in a higher being or an afterlife to consider the integrity of every breath you take. We may not all be destined for "great things" like becoming a celebrity, or writing a bestselling novel, or finding the cure for cancer. Some of us may just work hard all our lives, live paycheck to paycheck, and struggle to survive. That doesn't mean our efforts are in vain. There is a pride that comes along with offering your all for the ones you love. Some of us may not be able to work outside of the home for whatever reason. I am one of those, at least for now. My current mental health issues prevent me from driving and engaging in successful, panic-free social interactions with the public, which is very discouraging since I was able to work for most of thirteen years prior. It is my hope that my condition will improve and I will eventually be able to do those things again. In the mean time, however, I am not content to just sit around feeling sorry for myself. I have children to take care of, for one thing. Not everyone has children to keep them going (and when I say children, I mean in human and animal form). But if you search within yourself, look really hard, and ask yourself what you can do to brighten the corner you are in, you CAN and you WILL find something-even the smallest little thing-that makes your time on earth worthwhile, for both you and others. For me, I decided to use my time as a "hermit" to create my blog and Facebook page in order to reach out to others going through similar trials of mental illness and provide encouragement and support to as many as I can. Sure, that may not seem like a lot to some people. It won't pay the bills or make me famous. But it's a dear project to me, and while I help others it helps ME as well, and I get a lot of satisfaction out of what I am doing. Not everyone who is home bound will want to start a blog or Facebook page, but there may be something you have a knack for that you would like to learn more about and use those skills for a greater good. What is stopping you? You deserve to find fulfillment in life, whether that is from a job, a hobby, or any number of things that produce a positive aura around you and everyone you come in contact with. You owe it to yourself. You owe it to the world. Life is not to be taken for granted, and its uncertainties are not meant to be roadblocks to our ability to live wide open and feel the warmth of all the good in the world that is still present, despite all the cold parts. Don't keep the best of you locked away. It is meant to be shared.

Hello, 2013!

As 2012 draws to a close, I hope you can all look back on the year and see how far you've come. Certainly, at times, there have been road blocks, detours, and dead ends, supposed failures and backward steps. But there have been victories as well, and I want you to focus on those for a moment, however small those victories may seem to you. Think about what aided you in your success. Was it persistence? Clarity of mind? Utilizing your strengths instead of your limitations? Whatever most attributed to your well being in the past year, make sure to carry it over to 2013. Leave behind the self-loathing and criticism. Plan to spend more time with those who lift you up, and less time (or no time, if possible) with those who trample on your self-esteem and emotions. Figure out the top 3-5 priorities you want to set for the new year, and make sure your own mental health is at the top. You owe it to yourself to take care of your emotional needs, so that you can more successfully tackle everything else in your life. It is not selfish. It is vital! Don't let anyone convince you otherwise.

Happy New Year! I hope it's the best one yet!

An In-Depth Look at Eating Disorders

An eating disorder is an illness that causes serious disturbances to your everyday diet, such as eating extremely small amounts of food or severely overeating. A person with an eating disorder may have started out just eating smaller or larger amounts of food, but at some point, the urge to eat less or more spiraled out of control. Severe distress or concern about body weight or shape may also characterize an eating disorder.

Eating disorders frequently appear during the teen years or young adulthood but may also develop during childhood or later in life.^1,2 Common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder.

Eating disorders affect both men and women. For the latest statistics on eating disorders, see the NIMH website.

It is unknown how many adults and children suffer with other serious, significant eating disorders, including one category of eating disorders called eating disorders not otherwise specified (EDNOS). EDNOS includes eating disorders that do not meet the criteria for anorexia or bulimia nervosa. Binge-eating disorder is a type of eating disorder called EDNOS.³ EDNOS is the most common diagnosis among people who seek treatment.⁴

Eating disorders are real, treatable medical illnesses. They frequently coexist with other illnesses such as depression, substance abuse, or anxiety disorders. Other symptoms, described in the next section can become life-threatening if a person does not receive treatment. People with anorexia nervosa are 18 times more likely to die early compared with people of similar age in the general population.⁵

The Different Types of Eating Disorders

Anorexia Nervosa

 

Anorexia nervosa is characterized by:

• Extreme thinness (emaciation)
• A relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight
• Intense fear of gaining weight
• Distorted body image, a self-esteem that is heavily influenced by perceptions of body weight and shape, or a denial of the seriousness of low body weight
• Lack of menstruation among girls and women
• Extremely restricted eating.

Many people with anorexia nervosa see themselves as overweight, even when they are clearly underweight. Eating, food, and weight control become obsessions. People with anorexia nervosa typically weigh themselves repeatedly, portion food carefully, and eat very small quantities of only certain foods. Some people with anorexia nervosa may also engage in binge-eating followed by extreme dieting, excessive exercise, self-induced vomiting, and/or misuse of laxatives, diuretics, or enemas.

Some who have anorexia nervosa recover with treatment after only one episode. Others get well but have relapses. Still others have a more chronic, or long-lasting, form of anorexia nervosa, in which their health declines as they battle the illness.

Other symptoms may develop over time, including:^6,7

• Thinning of the bones (osteopenia or osteoporosis)
• Brittle hair and nails
• Dry and yellowish skin
• Growth of fine hair all over the body (lanugo)
• Mild anemia and muscle wasting and weakness
• Severe constipation
• Low blood pressure, slowed breathing and pulse
• Damage to the structure and function of the heart
• Brain damage
• Multiorgan failure
• Drop in internal body temperature, causing a person to feel cold all the time
• Lethargy, sluggishness, or feeling tired all the time
• Infertility.

Bulimia Nervosa

 

Bulimia nervosa is characterized by recurrent and frequent episodes of eating unusually large amounts of food and feeling a lack of control over these episodes. This binge-eating is followed by behavior that compensates for the overeating such as forced vomiting, excessive use of laxatives or diuretics, fasting, excessive exercise, or a combination of these behaviors.

Unlike anorexia nervosa, people with bulimia nervosa usually maintain what is considered a healthy or normal weight, while some are slightly overweight. But like people with anorexia nervosa, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape. Usually, bulimic behavior is done secretly because it is often accompanied by feelings of disgust or shame. The binge-eating and purging cycle happens anywhere from several times a week to many times a day.
Other symptoms include:^7,8

• Chronically inflamed and sore throat
• Swollen salivary glands in the neck and jaw area
• Worn tooth enamel, increasingly sensitive and decaying teeth as a result of exposure to stomach acid
• Acid reflux disorder and other gastrointestinal problems
• Intestinal distress and irritation from laxative abuse
• Severe dehydration from purging of fluids
• Electrolyte imbalance (too low or too high levels of sodium, calcium, potassium and other minerals) which can lead to heart attack.

Binge-Eating Disorder

 

With binge-eating disorder a person loses control over his or her eating. Unlike bulimia nervosa, periods of binge-eating are not followed by purging, excessive exercise, or fasting. As a result, people with binge-eating disorder often are over-weight or obese. People with binge-eating disorder who are obese are at higher risk for developing cardiovascular disease and high blood pressure.⁹ They also experience guilt, shame, and distress about their binge-eating, which can lead to more binge-eating.

Treatment For Eating Disorders

Adequate nutrition, reducing excessive exercise, and stop-ping purging behaviors are the foundations of treatment. Specific forms of psychotherapy, or talk therapy, and medica-tion are effective for many eating disorders. However, in more chronic cases, specific treatments have not yet been identified. Treatment plans often are tailored to individual needs and may include one or more of the following:

• Individual, group, and/or family psychotherapy
• Medical care and monitoring
• Nutritional counseling
• Medications.

Some patients may also need to be hospitalized to treat problems caused by malnutrition or to ensure they eat enough if they are very underweight.
 

Treating Anorexia Nervosa

 

Treating anorexia nervosa involves three components:

• Restoring the person to a healthy weight
• Treating the psychological issues related to the eating disorder
• Reducing or eliminating behaviors or thoughts that lead to insufficient eating and preventing relapse.

Some research suggests that the use of medications, such as antidepressants, antipsychotics, or mood stabilizers, may be modestly effective in treating patients with anorexia nervosa. These medications may help resolve mood and anxiety symptoms that often occur along with anorexia nervosa. It is not clear whether antidepressants can prevent some weight-restored patients with anorexia nervosa from relapsing.¹⁰ Although research is still ongoing, no medication yet has shown to be effective in helping someone gain weight to reach a normal level.¹¹

Different forms of psychotherapy, including individual, group, and family-based, can help address the psychological reasons for the illness. In a therapy called the Maudsley approach, parents of adolescents with anorexia nervosa assume responsibility for feeding their child. This approach appears to be very effective in helping people gain weight and improve eating habits and moods.^12,13 Shown to be effective in case studies and clinical trials,¹⁴ the Maudsley approach is discussed in some guidelines and studies for treating eating disorders in younger, nonchronic patients.^11,12,15-18

Other research has found that a combined approach of medical attention and supportive psychotherapy designed specifically for anorexia nervosa patients is more effective than psychotherapy alone.¹⁹ The effectiveness of a treatment depends on the person involved and his or her situation. Unfortunately, no specific psychotherapy appears to be consistently effective for treating adults with anorexia nervosa.²⁰ However, research into new treatment and prevention approaches is showing some promise. One study suggests that an online intervention program may prevent some at-risk women from developing an eating disorder.²¹ Also, specialized treatment of anorexia nervosa may help reduce the risk of death.²²

Treating Bulimia Nervosa

 

As with anorexia nervosa, treatment for bulimia nervosa often involves a combination of options and depends upon the needs of the individual. To reduce or eliminate binge-eating and purging behaviors, a patient may undergo nutritional counseling and psychotherapy, especially cognitive behavioral therapy (CBT), or be prescribed medication. CBT helps a person focus on his or her current problems and how to solve them. The therapist helps the patient learn how to identify distorted or unhelpful thinking patterns, recognize, and change inaccurate beliefs, relate to others in more positive ways, and change behaviors accordingly.

CBT that is tailored to treat bulimia nervosa is effective in changing binge-eating and purging behaviors and eating attitudes.²³ Therapy may be individual or group-based.

Some antidepressants, such as fluoxetine (Prozac), which is the only medication approved by the U.S. Food and Drug Administration (FDA) for treating bulimia nervosa, may help patients who also have depression or anxiety. Fluoxetine also appears to help reduce binge-eating and purging behaviors, reduce the chance of relapse, and improve eating attitudes.²⁴

Treating Binge-Eating Disorder

 

Treatment options for binge-eating disorder are similar to those used to treat bulimia nervosa. Psychotherapy, especially CBT that is tailored to the individual, has been shown to be effective.²³ Again, this type of therapy can be offered in an individual or group environment.

Fluoxetine and other antidepressants may reduce binge-eating episodes and help lessen depression in some patients.²⁵

FDA Warnings on Antidepressants
 
Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects on some people, especially in adolescents and young adults. The FDA warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. For the latest information visit the FDA website.

Effect of Eating Disorders on Males

Like females who have eating disorders, males also have a distorted sense of body image. For some, their symptoms are similar to those seen in females. Others may have muscle dysmorphia, a type of disorder that is characterized by an extreme concern with becoming more muscular.26 Unlike girls with eating disorders, who mostly want to lose weight, some boys with muscle dysmorphia see themselves as smaller than they really are and want to gain weight or bulk up. Men and boys are more likely to use steroids or other dangerous drugs to increase muscle mass.²⁶

Although males with eating disorders exhibit the same signs and symptoms as females, they are less likely to be diagnosed with what is often considered a female disorder.²⁷ More research is needed to understand the unique features of these disorders among males.
 
Researchers are finding that eating disorders are caused by a complex interaction of genetic, biological, behavioral, psychological, and social factors. But many questions still need answers. Researchers are using the latest in technology and science to better understand eating disorders.

One approach involves the study of human genes. Researchers are studying various combinations of genes to determine if any DNA variations are linked to the risk of developing eating disorders.

Neuroimaging studies are also providing a better understanding of eating disorders and possible treatments. One study showed different patterns of brain activity between women with bulimia nervosa and healthy women. Using functional magnetic resonance imaging (FMRI), researchers were able to see the differences in brain activity while the women performed a task that involved self-regulation (a task that requires overcoming an automatic or impulsive response).²⁸

Psychotherapy interventions are also being studied. One such study of adolescents found that more adolescents with bulimia nervosa recovered after receiving Maudsley model family-based treatment than those receiving supportive psychotherapy, that did not specifically address the eating disorder.²⁹

Researchers are studying questions about behavior, genetics, and brain function to better understand risk factors, identify biological markers, and develop specific psychotherapies and medications that can target areas in the brain that control eating behavior. Neuroimaging and genetic studies may provide clues for how each person may respond to specific treatments for these medical illnesses.

 

Citations

1. Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating disorders. New England Journal of Medicine, 1999; 340(14):1092–1098.
2. Steiner H, Lock J. Anorexia nervosa and bulimia nervosa in children and adolescents: a review of the past ten years. Journal of the American Academy of Child and Adolescent Psychiatry, 1998; 37:352–359.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Washington, DC: American Psychiatric Press, 1994.
4. Fairburn CG, Cooper Z, Bohn K, O’Connor ME, Doll HA, Palmer RL. The severity and status of eating disorder NOS: implications for DSM-V. Behaviour Research and Therapy, 2007; 45(8):1705–1715.
5. Steinhausen HC. Outcomes of eating disorders. Child and Adolescent Psychiatric Clinics of North America, 2008; 18:225–242.
6. Wonderlich SA, Lilenfield LR, Riso LP, Engel S, Mitchell JE. Personality and anorexia nervosa. International Journal of Eating Disorders, 2005; 37:S68–S71.
7. American Psychiatric Association (APA). Let’s Talk Facts About Eating Disorders. 2005. Available online at http://www.healthyminds.org/Document-Library/Brochure-Library/Eating-Disorders.aspx.
8. Lasater L, Mehler P. Medical complications of bulimia nervosa. Eating Behavior, 2001; 2:279–292.
9. National Institutes of Health National Heart Lung and Blood Institute. Why obesity is a health problem. http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/healthy-weight-basics/obesity.htm. Accessed on May 3, 2010.
10. Walsh BT, Kaplan AS, Attia E, Olmsted M, Parides M, Carter JC, Pike KM, Devlin MJ, Woodside B, Roberto CA, Rockert W. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. Journal of the American Medical Association, 2006; 295(22): 2605–2612.
11. Agency for Healthcare Research and Quality (AHRQ), Management of Eating Disorders, Evidence Report/Technology Assessment, Number 135, 2006. AHRQ publication number 06-E010, www.ahrq.gov.
12. Eisler I, Dare C, Hodes M, Russell G, Dodge E, and Le Grange D. Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry, 2000; 1:727–736.
13. Lock J, Le Grange D, Agras WS, Dare C. Treatment Manual for Anorexia Nervosa: A Family-based Approach. New York: Guilford Press. 2001.
14. Russell GF, Szmuckler GI, Dare C, Eisler I. An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 1987; 44:1047–1056.
15. Lock J, Agras WS, Bryson S, Kraemer HC. A comparison of short-and long-term family therapy for adolescent anorexia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry, 2005; 44:632–639.
16. Lock J, Couturier J, Agras WS. Comparison of long-term outcomes in adolescents with anorexia nervosa treated with family therapy. Journal of the American Academy of Child and Adolescent Psychiatry, 2006; 45:666–672.
17. National Institute for Clinical Excellence (NICE). Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa, and binge eating disorder. London: British Psychological Society. 2004.
18. Eisler I, Simic M, Russell G, Dare C. A randomized controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-year follow-up. Journal of Child Psychology and Psychiatry, 2007; 48(6):552–560.
19. McIntosh VV, Jordan J, Carter FA, Luty SE, McKenzie JM, Bulik CM, Frampton CM, Joyce PR. Three psychotherapies for anorexia nervosa: a randomized controlled trial. The American Journal of Psychiatry, 2005; 162:741–747.
20. Halmi CA, Agras WS, Crow S, Mitchell J, Wilson GT, Bryson S, Kraemer HC. Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs. Archives of General Psychiatry, 2005; 62:776–781.
21. Taylor CB, Bryson S, Luce KH, Cunning D, Doyle AC, Abascal LB, Rockwell R, Dev P, Winzelberg AJ, Wilfley DE. Prevention of eating disorders in at-risk college-age women. Archives of General Psychiatry, 2006; 63(8):881–888.
22. Lindblad F, Lindberg L, Hjern A. Improved survival in adolescent patients with anorexia nervosa: a comparison of two Swedish national cohorts of female inpatients. American Journal of Psychiatry, 2006; 163(8):1433–1435.
23. Wilson GT and Shafran R. Eating disorders guidelines from NICE. Lancet, 2005; 365:79–81.
24. Romano SJ, Halmi KJ, Sarkar NP, Koke SC, Lee JS. A placebo-controlled study of fluoxetine in continued treatment of bulimia nervosa after successful acute fluoxetine treatment. American Journal of Psychiatry, 2002; 151(9):96–102.
25. Arnold LM, McElroy SL, Hudson JI, Wegele JA, Bennet AJ, Kreck PE Jr. A placebo-controlled randomized trial of fluoxetine in the treatment of binge-eating disorder. Journal of Clinical Psychiatry, 2002; 63:1028–1033.
26. Pope HG, Gruber AJ, Choi P, Olivardi R, Phillips KA. Muscle dysmorphia: an underrecognized form of body dysmorphic disorder. Psychosomatics, 1997; 38:548–557.
27. Anderson, AE. Eating disorders in males: critical questions. In R Lemberg (ed), Controlling Eating Disorders with Facts, Advice and Resources. Phoenix, AZ: Oryx Press, 1992; 20–28.
28. Marsh R, Steinglass JE, Gerber AJ, Graziano O’Leary K, Wang Z, Murphy D, Walsh BT, Peterson BS. Deficient activity in the neural systems that mediate self-regulatory control in bulimia nervosa. Archives of General Psychiatry. 2009; 66(1):51–63.
29. Le Grange D, Crosby RD, Rathouz PJ, Leventhal BL. A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa. Archives of General Psychiatry. 2007; 64(9):1049–1056.

This article is in the public domain of NIMH publications and may be reproduced or copied without the permission from the National Institute of Mental Health. For complete guidelines regarding the reproduction of this article, you may call their Information Resource Center at 1-866-615-6464 or send an email to nimhinfo@nih.gov.

“I've learned that no matter what happens, or how bad it seems today, life does go on, and it will be better tomorrow.

I've learned that you can tell a lot about a person by the way he/she handles these three things: a rainy day, lost luggage, and tangled Christmas tree lights.

I've learned that regardless of your relationship with your parents, you'll miss them when they're gone from your life.

I've learned that making a "living" is not the same thing as making a "life."

I've learned that life sometimes gives you a second chance.

I've learned that you shouldn't go through life with a catcher's mitt on both hands; you need to be able to throw something back.

I've learned that whenever I decide something with an open heart, I usually make the right decision.

I've learned that even when I have pains, I don't have to be one.

I've learned that every day you should reach out and touch someone. People love a warm hug, or just a friendly pat on the back.

I've learned that I still have a lot to learn. I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel."

-Maya Angelou

Let us try to have a stress-free Christmas, shall we? I've been beating myself up for getting behind on everything while I was sick this past week, but self-loathing never helped anyone, so instead I am going to focus on the positive. We have a great meal planned, and I look forward to spending time with my family. I may have to take breaks along the way,  I may have to go to the other room for a breather here and there, but the important thing is that I keep my efforts focused on the things that truly matter, and to not get bogged down emotionally with the silly things like having everything just right like a good hostess "should". I'm Amy. I don't have it altogether. Not at Christmas, not ever. My nerves will be frazzled to a certain extent regardless. But I am strong and I can do my best, and that is perfectly good enough. What's more, my family loves me just the way I am, frazzled and not-together and emotionally unstable as I can be. They don't require me to be perfect. They just want me to be present. That's all any of us really have to be. Present and open to the days, the moments, the memories. Do what you can, and let that be enough. I wish you all a wonderful and memorable holiday. Be safe, be merry, and be your beautiful self!