Authors: Kathryn Hansen
37
: Coexisting Problems
R
esearch does show a frequent correlation between bulimia and other psychiatric conditions.
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Those diagnosed with bulimia are often diagnosed with a coexisting problem, such as depression, anxiety, substance abuse, or personality disorders.
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Coexisting problems are called "comorbidities" by health professionals, and it's been shown that about 75 percent of bulimics are affected by other behavioral, emotional, or psychological problems.
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It's often difficult to tell if the coexisting problems are the consequences of the behavior or if they are the traits that make one more vulnerable to developing bulimia in the first place.
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In my case, I was diagnosed with depression and anxiety, and as I've discussed, I spent much time in therapy addressing these coexisting problems, hoping that would make my urges to binge go away. Even if fixing coexisting problems could have completely eliminated my urges to binge, it still would have been a gargantuan task. I think that I may always be prone to depression and high anxiety. This doesn't mean I have to resign myself to those problems and do nothing to help myself change; it only means that if I were still waiting for my coexisting problems to go away in order to stop my habit of binge eating, I would still be waiting, because my anxiety and depressive tendencies seem to be stubborn parts of who I am.
I believe that even if I would have solved my depression and anxiety—fully and completely—it would not have cured my bulimia. If I would have overcome depression, I would have overcome depression; if I would have learned to manage my anxiety well, I would have learned to manage my anxiety well. Bulimia is a separate problem with a separate cure.
This is not to say there is no correlation between bulimia and coexisting problems. I believe coexisting problems can be one of three things:
COEXISTING PROBLEMS AS SUSCEPTIBIUTIES TO DIETING
Problems like depression and anxiety—if they exist prior to the development of disordered eating—can make someone more likely to diet and let that diet get out of control, which in turn can lead to the development of an eating disorder. If a young woman is depressed, she may begin restrictive dieting thinking thinness will make her happy. If a young woman has high anxiety, she may take a simple diet too far by worrying about every calorie and every pound. If a young woman has OCD, she may be more likely to become obsessive about her eating behavior.
I could theorize about how my own tendency toward high anxiety and depression played into my decision to diet, but none of it is hard fact. All that matters is that I had some susceptibilities, two of which were anxiety and depression, that made me more likely to diet and made dieting more likely to be problematic. After I binged for the first time, my high anxiety probably made me more likely to purge, setting the binge-purge cycle in motion, which led to habit formation.
COEXISTING PROBLEMS AS RESULTS OF BULIMIA
The coexisting problems that I experienced while I was bulimic were often consequences of the bulimia itself. It was often difficult to tell which problems were results of binge eating and which were separate problems. It was hard to remember which issues existed before the binge eating started, because I looked into my past with bias. Once I learned that problems like depression and anxiety can cause eating disorders to develop, it was easy to look back and find instances of depression and anxiety in my childhood.
Once bulimia developed, it only compounded whatever anxiety and depression I did have, because binge eating was a constant source of stress and sadness. Once I ended my habit and took away that source of guilt, isolation, self-hatred, and stress, much of my anxiety and depression alleviated. Even if I was more anxious or depressed than the average person before developing bulimia, and even if I am more anxious and depressed than the average person now that I am recovered, one thing is for certain: my binge eating made it
so
much worse.
COEXISTING PROBLEMS AS REASONS BULIMICS DON'T WANT BETTER FOR THEMSELVES
In the winter of my senior year of college, my binge eating was the worst it had ever been, and my depression increased greatly, to the point that it made me apathetic toward recovery. I couldn't see a way out. I thought I would be doomed to binge for the rest of my life. I was completely exhausted, and I didn't see the point of trying anymore. I gained weight rapidly and binged continuously, sometimes for days at a time. I stopped trying to fight, which had never helped me quit in the past, but at least a fighting spirit helped me from completely folding. My depression allowed me to resign to my lower brain and let it have complete control.
I didn't care what health consequences I was suffering, and some days I wasn't sure if I wanted to live anymore, let alone recover. My relationships fell by the wayside, and I felt like my life had no direction or purpose. My highest human brain temporarily gave up and my habit completely took over. Luckily, I snapped out of this low state of mind and began trying to recover again. However, my ways of trying to recover at that time—therapy's methods—were not effective, so I continued to binge even when my severe depression lifted.
With the right information, I think I could have conquered my habit even during that time of severe depression; but I think it would have been much harder to capture the power of my highest human brain when I felt so low. To stop my habit, I had to know that my true self was powerful, capable of overriding the automatic functions of my brain. Even with the right information and tactics for handling my urges to binge, my true self might have needed a little boost in the form of depression treatment— medication or some other alternative. This was the only time during my bulimia that I could argue that treating my depression first—so that it lifted slightly—prior to stopping the habit might have made some sense; but otherwise, it was unnecessary for recovery.
WHAT TO SOLVE FIRST?
In the majority of cases where coexisting problems are present (except, perhaps, for severe depression), I would argue it simply makes more sense to solve the bulimia first. It's a losing battle to try to solve problems that are the results of bulimia while continuing to indulge the habit; furthermore, solving the bulimia is the only way to see which problems truly are separate problems and which are consequences of the bulimia itself. Bulimia and BED are usually the simplest and most clear-cut problems to solve with the most straightforward cure: stop binge eating. If some problems don't go away completely after the binge eating stops, at least the woman will be more clearheaded to tackle the conditions that remain. Or she may find that the coexisting problems are not significant without the bulimia amplifying them and, thus, that there is nothing left from which to recover.
38
: Medication
D
rugs are often used to treat anxiety, depression, or other conditions that coexist with bulimia or BED; but some drugs are prescribed specifically to treat bulimia or BED itself. Antidepressants are the most commonly prescribed,
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although only one antidepressant—Prozac (fluoxetine)—has been approved by the Food and Drug Administration to treat bulimia.
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During the course of my bulimia, I took Prozac as well as two other types of antidepressants.
SEROTONIN
Prozac, and antidepressants like it, are selective serotonin reuptake inhibitors (SSRIs), which work by increasing the level of the neurotransmitter serotonin in the brain.
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Serotonin is associated with appetite and mood.
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Low serotonin levels are linked to low mood and increased appetite, and high serotonin levels are linked to elevated mood and decreased appetite. Since bulimics and those with BED show symptoms of low mood and increased appetite, they are often assumed to have low serotonin levels. A serotonin deficit may be related to bulimia;
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however, it's unknown whether these chemical abnormalities precede the eating disorder or are consequences of the eating disorder.
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A popular theory of bulimia and BED is that binge eating results from these low serotonin levels.
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Bulimics binge eat to raise their serotonin levels and therefore improve their mood, decrease stress, and alleviate depression.
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So, as this theory would have it, binge eating is a form of subconscious self-medication.
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The carbohydrate cravings, then, are a means of the brain trying to correct a chemical imbalance—in this case, of serotonin.
Although binge eaters may indeed have low serotonin levels, believing this theory led to two problems for me.
Problem 1: False Expectations for a Cure
The measure of any theory or course of treatment is effectiveness. If low serotonin levels are the true cause of binge eating, then the antidepressant medications I took would have been fail-safe treatments. If I had only been bingeing to raise my serotonin levels, then increasing serotonin in my brain would have eliminated all binge eating. But antidepressants did not cure my bulimia, and they do not cure all cases of bulimia. No antidepressant—or any other psychiatric drug, for that matter—has been shown to stop binge eating. Although Prozac and other types of antidepressants have been shown to lessen bingeing and purging in the short term, and lessen depressive symptoms overall,
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that is not a cure.
Antidepressants and other psychiatric drugs were not acting directly on my real problem: my urges to binge. No drug completely and permanently erased those urges, although Topamax temporarily reduced them greatly. No drug could undo my habit; no drug could change those faulty neural pathways that I created by binge eating over and over again; no drug could correct my binge-created brain-wiring problem. Even though psychiatric drugs did indeed have a physical effect on my brain, and the antidepressants I took certainly elevated my mood, those brain changes could not cure my bulimia.
Furthermore, I think I expected the drugs to provide the secondary benefits of binge eating. But a psychiatric drug can't do that. Medication didn't taste good, it didn't feel good going down, and it didn't provide instant satisfaction, distraction, or numbness—all of the things I came to crave once the binge eating was established. By expecting a pill to take away my desire for those secondary benefits, I was setting myself up for disappointment. Nothing else could provide those benefits; the hard truth was, I just had to give them up.
Problem 2: The Serotonin Theory Gave Me Excuses to Binge
Like so many concepts and theories touted by traditional therapy, the serotonin theory of bulimia gave me excuses—two of them, in particular—to keep following my urges to binge.
Excuse #1: When I am happy and feel good, I will stop binge eating.
I knew that the serotonin-raising antidepressants and other drugs I was prescribed were designed to improve my mood, which in turn was supposed to take away my "need" to binge eat. The serotonin theory promoted the harmful mind-set that I needed to feel good and be happy—through psychiatric drugs or other means—in order to stop binge eating.
So what happened when I did not find happiness and continued to feel low? My brain used that to produce self-pitying thoughts and feelings that encouraged me to binge. When I felt low, I believed I was justified in continuing to binge eat because, after all, bingeing was the "only thing" that made me feel good and elevated my mood (at least that's what my brain told me). I knew better, and I knew any good feelings bingeing gave me simply weren't worth it.
What's more, there were times during my bulimia when the antidepressants were effective in elevating my mood, or when I was just happier in general, without the use of medication, but I nevertheless continued having urges to binge and continued binge eating—maybe slightly less, but continued all the same. When this happened, I thought maybe I just wasn't happy enough. Maybe if I could feel just a little better, a little more fulfilled in my life, then I could stop binge eating. This endless quest for a higher level of happiness could have gone on indefinitely without ever stopping my habit.
As I talked about in Chapter 35's discussion of triggers, binge eating
can
be associated with low moods and negative events more than positive ones. This is because when a woman is feeling down, she may crave something to make her feel better; and, of course—if the woman is a binge eater—the first thing her brain will habitually suggest is food, lots and lots of food. So, theoretically, if the woman felt down less often—say, with the help of drugs to increase her serotonin level—she may crave binge eating less often.
Yes, medication can address triggers by taking away the stimulus (e.g., feeling depressed and lonely) so that the response (the urge to binge) doesn't occur. However, because a bulimic's urges to binge don't occur solely in response to feelings of depression and loneliness, she will still have the urges; and if she doesn't know how to deal with them, she will still binge. Additionally, if the medication's effects wear off or if she stops taking it, her depression and loneliness will return and her urges will again escalate.
I am glad I did not attribute my recovery to increased happiness or elevated moods, because that would put me constantly at risk for relapse. Inevitable low moods and unhappiness would automatically make me think that I needed to binge. Whether it relates to recovery or relapse, the mindset that feeling good equals a cessation of binge eating is dangerous.
For me, feeling good through medication (while still binge eating) was probably more dangerous than binge eating without the mood-elevating effects of medication. The best example of this was when I was first prescribed Prozac during the second semester of my freshman year of college. After a few weeks on the medication, my mood certainly improved, to the point that I was almost giddy. It felt unnatural, but I enjoyed the huge lift that the medication gave me. Although feeling better gave me a sunnier outlook on life, my elevated mood actually served to make me nonchalant about my binge eating and purging.
When I binged and purged, I didn't feel very guilty—I didn't worry about it much at all. But just because I felt less guilt, shame, and stress surrounding my destructive behaviors didn't mean I stopped engaging in those behaviors. The medication was not a cure, and it was also not an improvement. A blasé attitude toward the seriousness of my problem was not conducive to recovery, and it put me at risk for ignoring dangerous health consequences.
Excuse #2: It's not really my fault—I have low serotonin levels!
The serotonin theory taught me that I binged for a deeper purpose. It taught me that I was "using" food to correct a physical defect in my brain—the lack of a specific neurotransmitter. This set me up to blame my behavior on my neurotransmitters and avoid personal responsibility. I adopted the harmful idea that "chemically caused eating is not your fault."
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I erroneously believed I was sick and binge eating was my medicine. Even if I did truly have low serotonin levels or some other chemical imbalance in my brain, and even if I still do, binge eating is surely not a cure for that problem. If I happened to talk to a doctor about possible low serotonin levels in my brain, I guarantee he would not recommend binge eating.
In any case, whatever chemicals were off balance in my brain didn't automatically propel me toward the refrigerator. I always had a choice because of my highest human brain. My individual brain chemistry may have given me tendencies to feel and act in certain ways, but all it gave me was tendencies. Although blaming my behavior on my brain chemistry allowed me to avoid responsibility, I found it infinitely more gratifying when I accepted responsibility for my behavior and chose to change it.
OTHER DRUGS
I have mentioned that opioids are a factor in the pleasurable and habit-forming nature of binge eating. Opioid blockers such as naloxone have been shown to decrease feeding and decrease a preference for sweets in animals;
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however, opioid blockers have been found to be an ineffective treatment for binge eating in humans.
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Likewise, drugs that block dopamine—another pleasurable brain chemical that may be involved in binge eating—are not effective in the treatment of eating disorders.
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Anti-epileptic drugs, like Topamax, have been shown to temporarily decrease or stop binge eating, but they have adverse side effects that limit their use in many eating disorder patients.
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BRAIN CHANGES WITHOUT DRUGS
I believe the ineffectiveness of these drugs—those that affect serotonin, opioids, dopamine, and even multiple systems like the anti-epileptics—show that we can't simply tweak one part of the brain or one chemical process to effect major and lasting changes. Eating is far too complex of a behavior for that. Too many brain regions, neurochemicals, and hormones are involved in eating—in the brain itself and in the peripheral nervous system. Maybe one day, as our understanding of the nervous system improves, scientists will be able to come up with a medication that fixes all the right brain and peripheral chemicals and systems—completely and permanently. But if that ever occurs, what side effects will that medication have? Will all the artificial changes be worth it—just for an easy fix for a binge-created brain-wiring problem?
I believe that I was able to access all the right neurochemicals and brain systems that drove my habit through safe and natural behavior change. No medications required.
BRAIN CHEMICAL IMBALANCES AS VULNERABILITIES
As I've said before, of course there was something different about me that made me susceptible to dieting, overly restrictive dieting, and prone to develop the habit of binge eating. Brain chemical differences certainly could have been one of those factors. Maybe some of those chemical differences caused me to enjoy dieting when I first began; maybe some of them explain why my survival drives were so strong; maybe some of them provide reasons for why I derived pleasure from binge eating, why large amounts of highly palatable foods were addicting to me, why my lower brain developed and held on to my habit.
Maybe the particular makeup of my brain made me more likely to make the wrong choices when it came to dieting and binge eating; and without knowing what was going on in my brain, I followed my neurochemicals into those wrong choices. This is not my way of excusing the choices I made. I'm only saying that something surely made me susceptible to bulimia in the first place. But that didn't matter when it came to recovery. I still retained the ability to overcome my automatic brain functions; I still retained the ability to put brain over binge. Even if I did have differences or abnormalities in the makeup of my neurotransmitters, I no longer had to let it lead me into the wrong actions.
My change of perspective about brain chemicals is best summed up by Dr. John J. Ratey in
A User's Guide to the Brain:
"blaming yourself for the physiological shortcomings of your brain, whatever they may be, is misdirected energy, energy better spent in changing your habits and lifestyle to live the most productive life you can."
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