38: Medication
Drugs 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,232 although only one antidepressant—Prozac (fluoxetine)—has been approved by the Food and Drug Administration to treat bulimia.233 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.234 Serotonin is associated with appetite and mood.235 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;236 however, it's unknown whether these chemical abnormalities precede the eating disorder or are consequences of the eating disorder.237
A popular theory of bulimia and BED is that binge eating results from these low serotonin levels.238 Bulimics binge eat to raise their serotonin levels and therefore improve their mood, decrease stress, and alleviate depression.239 So, as this theory would have it, binge eating is a form of subconscious self-medication.240 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,241 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."242 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 serotoni
n 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;243 however, opioid blockers have been found to be an ineffective treatment for binge eating in humans.244 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.245 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.246
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."247
39: Prevention
I often think of things that may have kept me from developing bulimia in the first place, and there is only one thing that would have prevented it: avoidance of dieting. If I could have somehow avoided dieting, I could have avoided an eating disorder. So what would have prevented me, and what will prevent other young women from dieting?
Restrictive dieting is serious and potentially dangerous, especially in young people, but I don't believe the dangers are clearly communicated. Dieting is praised in our culture, and the aim to prevent it in young people isn't strong enough. I often see advertisements to discourage kids from taking drugs, which are sometimes terrifying in nature. I've seen billboards showing a ghastly figure of a drug addict; I've heard a radio commercial featuring an addict talking about all the horrible consequences he faced as a result of his drug use. Police go to high schools and put on chilling presentations about the risks of drinking and driving. None of this is done in regard to dieting.
Since eating disorders are viewed as diseases, like diabetes or lupus, plenty of groups—like the National Eating Disorders Association—raise awareness about them, just as the American Cancer Society raises awareness about cancer. It's fine to raise awareness about eating disorders, but that's not a preventive measure. That only promotes the idea that eating disorders are illnesses that inexplicably happen to people, when in fact nearly all cases of anorexia and bulimia, and a large number of cases of BED, would never occur without the initial diet, just like a drug addiction would never occur without that first hit.
There are susceptibilities to eating disorders just like there are susceptibilities to drug addictions, but the first diet, like the first hit of a drug, is not inevitable based on those susceptibilities. It's a choice, and one that can be prevented. When parents tell their kids not to smoke, they say, "Don't smoke" and possibly inform them of the horrible consequences of smoking. They don't say, Smoking is a disease you should be aware of. I'm not suggesting that scare tactics are the most effective way to prevent restrictive dieting, smoking, drinking and driving, or drug abuse; but there have to be measures to discourage all of these behaviors in young people. Restrictive dieting should not be excluded from the list of detrimental behaviors, and it should definitely not be praised.
PREVENTION CAN BE COMPLEX
I realize that "don't diet" is a more complicated message than "don't smoke" because smoking is clearly definable and dieting is not so clear-cut. Cutting back on junk foods and cutting down excessive portions is not truly "dieting;" it's learning to eat healthier. But even healthy improvements can have the effect of throwing the body from homeostasis and triggering survival instincts. In other words, the diet doesn't necessarily have to be restrictive to cause problems. Adolescents in a situation where they need to make changes to become healthier should be educated about survival instincts and why their bodies initially protest even healthy changes in eating habits. They should also be encouraged that soon, if they stick to it, healthy changes will become habitual and effortless.
Discouraging dieting is also a tough issue in that it could send the wrong message; that is, it could encourage teens to eat excessively in the name of "not dieting." Furthermore, harping on adolescents' eating habits to ensure they don't diet could run the risk of making them overthink their eating and lose touch with their natural hunger and fullness cues. Because of these issues and more, I'm not claiming there is an easy answer to dieting prevention, but I do think there are three things that may have helped me avoid dieting in the first place. I'm not blaming any of these factors for my own choices, but I believe that the following changes may have helped me choose to keep eating naturally.
Less Emphasis on Weight in the Family
Too many young women are raised by mothers and sometimes fathers obsessed with their weight, talking about their diets and workout plans, talking about how fattening certain foods are, lamenting about parts of their bodies they consider fat. I don't need to share exact details about my own family's issues surrounding weight while I was growing up to admit that there were definitely issues. There were comments—nothing too outrageous or out of the ordinary—that led me to believe that any excess weight was not preferable, and not just for health reasons, but for personal worth. I pe
rsonally believe weight and food should be discussed in a family in the context of health, not in the context of appearance. I think positive role models, both in and out of the family, could do much good in dieting prevention.
More Preparation for Weight Changes During Puberty
Because my background involved believing that weight gain was bad, puberty was more worrisome than it should have been. Now, with perspective, I know that the natural weight gain I experienced in puberty would not have kept up indefinitely. My body would have leveled off at a natural weight—a woman's weight, not a child's—and it would not have escalated to me being overweight. Back then, I needed to know that the extra weight in puberty was healthy, normal, and beneficial, not only for my future childbearing years, but in the present for athletics and strength. I wish I would have welcomed the change. I sometimes see skinny little girls like I was and hope they are prepared for weight gain later in life. Since being thin is praised so much, I think skinny girls risk fighting the change or lamenting the loss of their girlish bodies even more than others do.
Knowledge of Ineffectiveness of Restrictive Dieting
When I started dieting after my tonsillectomy, my parents recognized it soon enough. However, their main message, it seemed, was to try to convince me there was nothing to worry about, that I was thin and didn't need to lose any weight. I remember asking to buy a diet book in Walmart one day and my mom telling me that I was skinny and didn't need to diet. I'm not saying theirs was the wrong approach, and it was certainly well-meaning; but it wasn't effective. Telling me not to worry about my weight when I'd clearly watched it go up in recent years wasn't going to quell my concerns. The message I got was, You are still skinny, so stop worrying about it. From this message, I took away, You better watch out, because if you don't cut back on calories, you won't be skinny anymore.
Brain Over Binge Page 26