I did learn something useful from studying triggers. After I stopped binge eating, it was helpful for me to know that some situations were more likely than others to cause urges to binge. I knew that certain foods, feelings, thoughts, and interactions were particularly likely to cause my brain-wiring problem to flare up. There was nothing inherently wrong with those trigger situations or my ability to handle them, but there was something wrong with my lower brain's reaction to them. In the weeks and months after I quit bingeing, I expected my lower brain to act up when I encountered my former triggers, and when it did, I made sure not to let it affect me. As long as I put brain over binge—viewing the urges as simply neurological junk and unrelated to my ability to cope with any given trigger—it was simple not to act on them.
During that period, every time I encountered a trigger—such as eating at a restaurant with my parents—without binge eating, I taught my brain something new: that I no longer binged in response to that trigger. Without knowing it at the time, I was breaking all of my old stimulus-response patterns by not following my urges to binge. In behavioral psychology, this process is called "extinction": the gradual disappearance of a conditioned response to the stimulus.225 The most famous—and, in fact, the first—example of stimulus-response patterns and extinction was observed in the dogs of Ivan Pavlov.226
Pavlov conditioned the dogs to expect food after the sound of a bell, and a stimulus-response pattern soon formed. The dogs began salivating whenever they heard that bell, prior to the food arriving. The bell was the stimulus, which produced the response of salivation. However, if Pavlov stopped providing food after the sound of the bell, the dogs gradually ceased salivating when they heard the bell. In other words, if Pavlov took away the reward (the food), the stimulus (the bell) stopped evoking the response (salivation). It was the same with my binge eating. When I took away my lower brain's reward (the binge), all stimuli (triggers) stopped evoking the response (the urges to binge).
After I had encountered an urge-producing trigger a few times without providing my brain its reward, I noticed that the urges to binge faded in response to that trigger. Soon, I could have arguments with family or my husband without binge eating popping into my mind; I could feel depressed, anxious, or lonely, and my lower brain would not generate even the slightest urge to binge. The lower functions of my brain were like the child in the toy store—once he learns that tantrums won't get him what he wants, he will stop throwing them.
GETTING EXCITED ABOUT FACING TRIGGERS
Once I began seeing my urges to binge as the real problem, and I truly felt the power of my highest human brain over them, I found that I actually liked facing my old trigger situations. I found it empowering to know that my lower brain was going to act up, then feel it do so, all the while knowing I was not going to take it seriously. I got excited about overcoming my trigger situations—not by always coping well, but by simply not binge eating—and my excitement not only made me feel good, but I believe it solidified the changes in my brain. Since no situation was inherently dangerous, I no longer had to fear certain "triggering" people, places, foods, feelings, or situations, because I knew that nothing I encountered could make me binge. The situations I faced weren't always easy, but that's just life.
36: Purging
Apurge is a compensatory behavior—meaning it compensates for, or makes up for, something. That something is a binge. Take away the binge, and the purge serves no purpose. When I stopped binge eating, it followed that I simultaneously stopped purging. Why would I go through the misery of spending hours and hours exercising if I didn't binge eat? It simply wouldn't be necessary.
Purging was not a part of a disease I had; and in fact, purging was in no way a sign of psychological impairment. Although it was an unhealthy behavior, my purging began as a semi-rational attempt to undo the damage of each binge. Looking back at the beginning stages of my bulimia, when my survival instincts drove me to binge, reaffirms that there were two brain mechanisms at work: the survival instincts that produced those overwhelming urges to binge; and my true self. My true self was temporarily engulfed by urge after urge to binge; but once each binge was done, I returned to my senses and attempted to make up for what I had done.
In my case, my purging behaviors—overexercising and limiting food intake following a binge—weren't quite as dangerous or extreme as those of some other bulimics, because I physically couldn't make myself throw up (although if I could have at the time, I certainly would have). But even throwing up or abusing laxatives is not a sign of disease—it is the bulimic's attempt to take control back after a binge.
Until I knew what was going on in my lower brain, my true self felt powerless during each and every binge—as if it could see what was going on but could do nothing to stop it. So, I resorted to damage control. Once the binge was over and my true self returned, I felt I had to do something to compensate for my disgusting, gluttonous behavior—so I purged. Purging was never a good decision, but it was a rational decision made in times of desperation.
In therapy, I learned that purging, like bingeing, was a symbolic act that signaled a deeper emotional need or psychological problem. I learned that purging could be a form of self-punishment, a symbolic way of cleansing myself of unwanted feelings, an expression of anger, or a form of stress release. It was none of these things. It was a rash, yet understandable attempt to get rid of the massive amounts of food I knew I shouldn't have eaten.
PURGING BECAME HABITUAL TOO
Even though purging started as my own conscious—if bad—decision, it, too, became automatic and habitual as my bulimia progressed. This is because any behavior that is repeated enough gets relegated to the lower brain centers; then habit takes over. Purging became part of my whole binge-created brain-wiring problem, such that, after I binged, my brain automatically triggered an urge to purge. If I tried not to overexercise the day after I binged, I experienced strong urges to do so. I would get anxious and feel extreme guilt until I broke down and went to the gym. Even though overexercising was difficult and on some days excruciating, the feelings I had when I didn't purge were worse. I can imagine that the urges to purge are only amplified in those who practice self-induced vomiting, because the relief from guilt is so immediate.
Purging became linked to binge eating because my brain developed one of those stimulus-response patterns that I discussed in the previous chapter. Just as triggers produced urges to binge, binges became triggers that produced urges to purge. Bingeing and purging became physically linked in my brain, so that binge eating became the stimulus and the urge to purge became the response. When I took away the stimulus (binge eating), I by and large stopped having the response (the urge to purge). Since I never binged, the neural pathways that produce urges to purge never got a chance to fire. It was as if I'd put up a roadblock in my brain, so that the stimulus-response pattern never got set in motion.
However, I noticed that it was possible for my brain to generate a desire to purge even if I had not binged. Two situations sometimes brought this about.
1. The Urge to Purge from Simple Overeating
This was the situation where I was most likely to experience an urge to purge. If I ate a big meal or felt a bit too full, the feeling of fullness sometimes triggered a response similar to the response binge eating triggered. I found myself thinking, I can just work out for a long time tomorrow to burn it off.
The problem was, since fullness was part of the old stimulus of binge eating, my lower brain acted as if I had actually binged whenever I felt a bit too full. For a short while after I quit binge eating, I just had to live with this. I ignored the automatic messages telling me that I needed to overexercise simply because I ate a little too much, and soon, fullness stopped producing urges to purge.
2. The Urge to Purge When I Ate Former Binge Foods
No food can cause purging; but certain foods—especially those I used to binge on—sometimes created urges to purge just as they sometimes created urges to
binge. Even though I ate the former binge foods in normal quantities, my lower brain sometimes reacted nonetheless. It was reacting to the quality and type of food that I ate—sugary and fattening—and not necessarily the quantity.
For example, I used to binge on entire bags of potato chips; so if I ate a normal portion of potato chips, I sometimes had automatic thoughts telling me that I needed to work out more to make up for eating the chips. This doesn't mean chips were a problem or that I needed to eliminate them; it only meant that my lower brain had learned to associate eating chips with purging. Since I didn't act on my urges to purge, they soon went away.
DEALING WITH URGES TO PURGE
I dealt with urges to purge the same way I dealt with urges to binge. I recognized the urge as neurological junk—a remnant of my old habit—separated my highest human brain from the urge, didn't react emotionally to it, and, of course, didn't act on it. I remained aware of situations that could give rise to urges to purge, but I didn't need to avoid them or learn to cope well with them. I just knew that I didn't have to do what my lower brain was urging me to do. I could veto any eating disorder-related urge, whether it was to binge, to spend many hours in the gym, or to restrict my food intake after simple overeating. The neural connections that once produced my urges to purge simply faded away with lack of use; and now I can eat a big meal without any desire to compensate for it, and I can feel normal after exercising for only twenty minutes.
PURGING WITHOUT BINGE EATING
Before I end this chapter, there is one more issue to address. There are some with eating disorders who do not binge, but they nevertheless purge after normal meals or even after eating a very small amount. It is common for anyone who self-induces vomiting or abuses laxatives to consider herself "bulimic," but this is actually a misuse of the term. Bulimics—by definition—binge eat. When someone is purging regular meals or small amounts of food, she is engaging in a severe and dangerous form of restrictive dieting. Some have suggested that a new eating disorder—purging disorder—be added as a distinct classification.227
Purging without binge eating can be more complicated than bulimia or BED, I believe, for the same reasons that anorexia can be more complicated. If the woman sets out to lose weight, and that's what she is doing by purging, then she will have less motivation to quit. The purging may be ego-syntonic—in line with what her true self wants. Making it more difficult is the fact that purging can become addicting, so that any amount of food can trigger an urge to get rid of it. Furthermore, purging can lead to severe gastrointestinal problems, which can make keeping down any food painful and the urges to purge harder to resist.
Once the purging habit forms, the urges to purge are the only true cause of purging; however, the woman may have a hard time separating herself from those urges if she sees them as her true intention. Like I've stated previously, the first step in both traditional therapy and in my opinion is wanting to recover. Certainly, the advice I've given for resisting urges to binge and purge could apply to someone with purging disorder, but only once recovery is desired and the woman can see the urges as an unwanted intrusion in her life. The same holds for anorexia: once the woman can see the desire to starve as something apart from her highest self, only then can she overcome the problem.
37: Coexisting Problems
Research does show a frequent correlation between bulimia and other psychiatric conditions.228 Those diagnosed with bulimia are often diagnosed with a coexisting problem, such as depression, anxiety, substance abuse, or personality disorders.229 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.230 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.231
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:
Susceptibilities to dieting
Results of bulimia
Reasons bulimics don't want better for themselves
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 t
o 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.
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