The brain "craves" patterns and looks for them endlessly.217 The brain associates significant patterns with meaning, and attaches appropriate responses.218 I believe triggers are nothing more than "stimulus-response patterns" in the lower brain. A stimulus is any outside event or inner feeling that causes a response—an automatic reaction. All of us have many stimulus-response patterns, some instinctual and some learned. For instance, if a woman is walking alone at night down a dark alley (stimulus), she may automatically feel fear and become hyperalert (response). When a driver sees a red light (stimulus), his brain automatically prompts his foot to press the brake (response). When someone hears a loud noise across the room (stimulus), she will automatically flinch (response). When someone thinks about a happy memory from childhood (stimulus), he will automatically feel positive feelings (response). Everyone has stimulus-response patterns attached to many situations in their lives, whether they are aware of it or not.
Once a stimulus-response pattern is conditioned in the lower brain, the stimulus automatically triggers the response, beyond conscious control. When the stimulus is encountered, neurons fire automatically down familiar pathways, and the brain generates the response. Much of the time, such responses are sensible and sometimes even vital to one's existence—like pressing the brake or becoming hyperalert in a dark alley. Other times, the responses aren't vital, but they cause no harm—like flinching at the sound of a loud noise or feeling nostalgic when recalling memories. However, sometimes the lower brain attaches inappropriate and even dangerous responses to stimuli. This was the case with my binge eating.
By repeatedly binge eating in certain situations, I created stimulus-response patterns that were not healthy—in which a normal daily event or stressor caused an inappropriate response: an urge to binge. I followed urges to binge when I was alone in my house at night, when I was in my car driving home from a party, after a stressful day at school or work, when I was bored, when I had eaten a little too much at a meal, when I didn't have enough at a meal, when I was feeling sad, lonely, rejected, or anxious ... the list could go on and on. As my lower brain remembered where, when, and how I had binged, it easily became conditioned to maintain the patterns.
Let's take a look at how this played out in real life.
In the first month of my freshman year of college, about six months after I began binge eating, my parents came to visit my sister and me, and we all met at a restaurant for dinner. I was still trying to restrict my food intake between binges and still trying (in vain) to maintain my low weight. I had binged the day before, but I hadn't been able to exercise too much that day because of their visit. So I felt I shouldn't eat very much for dinner. I ordered a low-calorie sandwich and ate only half of it.
When I stopped eating, I couldn't help but see disapproving looks on my parents' faces—whether they were real or imagined. Corey ate only a meager portion of her own dinner, yet my parents didn't seem to notice that. At the time, my sister was cutting calories, increasing her exercise, and losing some weight—as the majority of young women attempt to do at one time or another (see Chapter 18). Given that Corey and I had a similar upbringing, this wasn't surprising; and luckily, her very different personality traits spared her from serious consequences. Nevertheless, at the time, seeing her limit her food intake only served to remind me of my lack of willpower. That meal, like most family meals while I had an eating disorder, had an underlying tension about the food. I didn't feel full after I'd finished half of my sandwich, and I struggled internally to keep myself from eating more of it, while my sister's scanty eating seemed, to me, to take no effort at all.
As I sat there staring at the other half of my sandwich, a familiar urge to binge arose. I stopped paying much attention to the conversation and began wishing I could leave the restaurant to get more food. I tried to talk myself out of it and fight off my cravings, but when I finally was alone again, I gave in and binged.
My urge to binge was a response to my undereating, but this experience taught my brain several stimulus-response patterns. My lower brain learned an association between binge eating and going to dinner with my parents, watching my sister eat small portions, feeling uneasy in conversation with my family, feeling resentful of others' eating habits, and, of course, not eating enough at a meal. The next time I encountered any of these situations or feelings, my brain was more likely to send out urges to binge.
THE LOWER BRAIN REMEMBERS WHAT GETS RESULTS
The lower brain remembers stimulus-response patterns because the brain is opportunistic; it quickly seizes on whatever gets it the desired results. In behavioral psychology, it's called the "law of effect": behavior followed by consequences that are satisfying to the organism will be repeated, and behavior followed by unpleasant consequences will be discouraged.219
The binge eater's lower brain is like a little boy who throws a tantrum in a toy store because he wants a toy. If his mother gives in and buys him the toy, this only ensures that the next time the boy and his mother are in a toy store, he will be more likely to repeat the tantrum. Why? Because the tantrum was effective—it got him exactly what he wanted. Or, put another way, the behavior was positively reinforced. The little boy's brain will now remember that whenever he enters a toy store (stimulus), he should throw a tantrum (response), and he will get the desired result. When the response gets the desired result, the brain is more likely to repeat the response when the stimulus is encountered again.220
It was the same with my lower brain. When it got what it wanted—a binge, and all the rewarding biochemical changes that came along with it—it remembered the events leading up to the binge and it learned to repeat the same tactics. It remembered what urges were successful and what urges weren't; and since an urge was successful after dinner with my parents, then dinner with my parents became a powerful stimulus that—more often than not—produced an urge to binge. The more times I followed that urge and repeated this pattern, the more cemented in my brain that association became.
Anyone with an addiction has to deal with stimulus-response patterns. For example, it's common to hear smokers say they can't have a beer without having a cigarette; and while there is nothing about a beer that physically requires a cigarette, there is a often a strong pattern of association in the smoker's brain between the two, because he has repeatedly smoked and drank simultaneously. Because the stimulus-response pattern is so strong, his brain will automatically send strong urges to smoke whenever he is drinking. If he even dares to try to drink without having a cigarette, his lower brain will throw a tantrum. It will kick and scream until it gets what it wants; and if the smoker keeps giving in, the tantrum will repeat indefinitely.
Trigger situations for my binge eating grew more numerous over time, which only makes sense in light of the brain. As I binged more and more in many different situations, I created more and more stimulus-response patterns. In addition to growing more numerous over time, my triggers also grew more generalized over time, so that the stimulus didn't have to be specific to produce an urge to binge. When the habit was firmly entrenched in my brain, anything that even resembled the stimulus produced a response—again, this was my lower brain being opportunistic. To illustrate this, I'll return to the example of eating in a restaurant with my parents. Once this was established as a stimulus-response pattern, I found that similar situations generated the same response. Soon, I had urges to binge not only after going to a restaurant with my parents, but after eating at home with my parents, after eating at a restaurant with friends, and after eating in any type of social situation.
Again, my lower brain was like the tantrum-throwing little boy. When the boy realizes the tantrum works in a toy store, he may try it in a grocery store, a fast-food restaurant, at home. If the tantrum works in any of these similar places, those places will become additional stimuli that automatically produce the response: a tantrum. Likewise, when my brain effectively got me to binge in a situation similar to the original stimulus, that similar situation
also produced an urge to binge.
WHY BINGES ARE OFTEN LINKED TO STRESSORS
Most bulimics report that their triggers are primarily negative events, thoughts, and feelings. In other words, bulimics often say that their binge eating "is preceded by situations they perceive as stressful,"221 and that's certainly what I reported to my therapists. Although this has some validity (which I will discuss soon), I believe reporting bias is a factor as well. When I was in therapy and searching for my triggers, I was seeking out only negative triggers, because that's what I thought I was supposed to do. Traditional therapy teaches that negative thoughts, feelings, and events cause binge eating, so that's what I focused on. If I had analyzed the binge after eating at a restaurant with my family, I would have blamed the binge on the tension of the meal, on watching my sister eat, on my parents' disapproval of my eating habits, or on another negative feeling.
If I looked hard enough, there was always something negative going on in my external or internal world before each binge, so I was always able to find a negative trigger. Furthermore, there was a benefit for me in the negative: it let me off the hook in my mind. If I could identify a negative trigger, I didn't feel as accountable for my own actions. I could blame the trigger for the binge, and this felt much better than blaming myself. If, in my mind, the binge was due to a fight with my boyfriend, a feeling of loneliness, or stress about an upcoming exam, I had an excuse for having engaged in such a disgusting and shameful activity.
But reporting bias aside, it did make some sense that my binge eating occurred more often following stressors than positive experiences. Why? Because of the secondary benefits of binge eating. It made me feel good, temporarily; so I automatically craved it when a little pleasure, distraction, numbness, or stress reduction was enticing. It's well known that eating reduces stress,222 even in those without eating disorders and even in animals. In some of the rat studies I've mentioned, the previously food-deprived rats binged on highly palatable foods after exposure to stress, whereas previously food-deprived rats not exposed to stress did not binge.223
In other words, stress did induce binge eating in the rats that were already rendered susceptible through a history of food deprivation. Stress and eating are certainly related, and this relationship is most likely mediated by the opioids.224 Like the food-deprived rats, I was probably susceptible to stress-induced binge eating. However, stress never triggered my binge eating, it only triggered my urges. Unlike the rats, I always had a choice—because of the capabilities of my highest human brain—of whether or not to follow those urges.
That my lower brain automatically produced urges to binge when I encountered negative thoughts, feelings, and events in my life was not an indication that I somehow needed to binge to cope with those things. There were simply strong patterns of association, so that my urges arose more often in the wake of negative circumstances and stressors; but always, I binged only to cope with the urge to binge. Negative thoughts, feelings, and events didn't cause binge eating prior to the development of my bulimia, and they don't cause binge eating now.
WHY DEALING WITH TRIGGERS WAS INEFFECTIVE
In the view of traditional therapy and specifically CBT, learning to cope with triggers—whether the trigger is a difficult external circumstance or a negative inner thought or feeling—should prevent most urges from arising and make existing urges go away. If, for example, I determined that feeling anxious led to binge eating, I could practice relaxation techniques as soon as anxious feelings arose, which should have prevented an urge to binge or stopped it once it started. If being alone at night led to binge eating, I could plan activities, and engaging in them should have prevented an urge to binge or stopped it once it started. These types of strategies were never effective for me, and I believe there were two reasons for that.
1. Dealing with the Triggers Was Not Addressing the Real Problem
In therapy, I identified my triggers and developed plans to deal with them, and I even tried avoiding some triggers altogether. Sometimes I decided not to go out drinking, solely because I feared I would binge when I got home; sometimes I stayed away from social situations, solely because they left me feeling inadequate—a feeling I believed triggered binges; sometimes I tried to avoid certain foods that I thought triggered binge eating. I had a long list of positive things to do when I felt lonely, sad, depressed, or anxious; I had action plans to deal with relationship conflicts and stressors at school and work.
Now that I know that the real problem was my urges to binge, I can see how unnecessary all of this was. Urges to binge led me to binge all those years—triggers didn't. Once my brain produced its response to a stimulus, trying to cope with the original stimulus did not erase the response.
Trying to substitute an alternative and emotionally fulfilling activity to deal with the trigger—like calling a friend to deal with loneliness—would be like the mother of the misbehaving boy in my example giving her child a hug instead of the toy for which he is screaming. The child will mostly likely reject the hug and escalate his tantrum. Even if he does have some unfulfilled emotional needs—as nearly everyone does, young or old—he isn't screaming for a hug; he is screaming because he wants the toy, and only the toy will do.
Moreover, dealing proactively with triggers—giving myself comfort and emotional fulfillment before urges could surface, as my therapists suggested I do—was also ineffective. To explain this, I'll return to the previous example of binge eating after going out with my parents.
When I began therapy, my therapists wanted to explore family dynamics and conflicts to see from where any stress might stem. In therapy, I pondered questions like these: Am I binge eating to rebel against my parents because they make me feel smothered? Am I binge eating as a way to get their attention? Am I binge eating to assert my independence from them? In theory, if I got to the bottom of my family conflicts and solved them, I could greatly reduce my binge eating. I found this not to be true. I can remember times when my parents came to visit and I truly had a great time, but I still had urges to binge and still binged.
Yes, I had some family conflicts at the time of my binge eating; but I also had them before my bulimia ever developed and before I ever dieted, and to this day, I have ever-changing family issues—nothing major, but I think most families are a bit dysfunctional in one way or another. The conflicts in my family prior to the development of my eating disorder didn't produce urges to binge; and after my recovery, they stopped producing urges to binge. This is because they were never the problem; family problems only became temporarily linked to binge eating.
Even if I could have managed to solve all of my family problems in therapy—which would have been unrealistic for any teenager or woman in her early twenties—it wouldn't have taken away my urges to binge. I still feel guilty that I ever blamed binge eating on others, especially my parents and sister, who have given me so much love and support over the years. The high school and college years are characteristically rocky times in the parent-child relationship; this is completely normal as teens assert their independence from their family of origin. For therapists to encourage young women like myself to see inevitable family conflicts as causes of eating disorders is, I believe, highly irresponsible, and it could even lead to permanent damage to family relationships.
2. Dealing with Triggers Was a Monumental Task
Even if dealing with triggers worked every time, which it didn't, it is a monumental task. To deal with triggers, I had to either avoid or learn to cope with all the situations, thoughts, and feelings that preceded binges, which could have been any of an infinite number of thoughts, situations, and feelings. Avoiding or coping with triggers diligently does have the possibility of preventing some urges in bulimics, because, as I've discussed, bulimics are more likely to have urges to binge when they feel bad and want some sort of pleasure, distraction, or numbness. So if a bulimic learns to cope well with all negative feelings, events, and thoughts, she may not crave pleasure or distraction
as much, and therefore, her urges to binge may decrease. But there is no guarantee, because once the body and brain are hooked on binge eating, the binge eater will still be driven to do it at times, even if she feels good otherwise.
I never even came close to the ideal of coping well with all of my triggers; I guess I wasn't good at fending off or dealing with negative feelings, thoughts, and events. But was this really only my problem? I think it was unrealistic for my therapists to expect me to cope well with everything negative in my life, especially when I was still very young. To deal with every event, feeling, thought, situation, conflict, or stressor that could potentially trigger an urge to binge would be an insurmountable and life-consuming task for anyone, especially a teenager or young adult. Although I did try to deal with the triggers, and I did discover some coping strategies that have served me well in my life (even though they didn't do much to stop binge eating), the enormous chore of dealing with triggers was simply unnecessary for my recovery.
In fact, I believe focusing on triggers gave me more ways to procrastinate about stopping my habit. I found myself saying things like, "When I stop being anxious staying in the house alone, I won't binge when I'm in the house alone," or "When I feel more comfortable in social situations, I'll stop bingeing when I get home from parties," or "When I can become organized and study well before exam time, I'll stop bingeing the night before exams." All of these excuses just served to keep me from taking control of my own behavior, regardless of the situation.
AWARENESS OF TRIGGERS WAS HELPFUL
Once I knew I was no longer a slave to my lower brain's automatic responses, triggers didn't bother me anymore. My lower brain certainly continued generating conditioned responses—the urges to binge—in trigger situations. Those urges, and all the thoughts and feelings that came along with them, were beyond my control. However, I knew my actions were always under my control, regardless of what—if anything—may have triggered my urges.
Brain Over Binge Page 24