Bulimia? Yes, you too.

While I have covered off orthorexia, anorexia athletica and of course all aspects of anorexia, people who visit this site are often confused about whether the Homeodynamic Recovery Method Guidelines really, really apply to those experiencing cycles of restriction and reactive eating, those with bulimia and those at average to above-average weights. The short answer is “Yes” (good, now you can go off and read more exciting things out there!)

For those who want a bit more substance to support that answer, let’s wade in.

Corinne Okada: Flickr.com

Corinne Okada: Flickr.com

Julie O’Toole, pediatrician, founder and director of the Kartini Clinic and author of Give Food A Chance mentions in her book that they separate those with anorexia and those with bulimia in their inpatient settings because anorexics tend to be very elitist and give the bulimics a hard time for being unable to control their hunger.

When it comes to the Homeodynamic Recovery Method Guidelines I find the perverse snobbery runs the other way. Those with bulimia condescendingly point out that these guidelines are more suitable for those who are really underweight and that it’s clear those anorexics require the extra energy, but they do not.

Presumably these types of slow slips from reality are how everyone found themselves drinking the Kool-Aid in Jonestown. I am not entirely joking. One of the dangers of identifying yourself with any chronic condition of any kind is that you can very quickly lose the forest for the trees if you are only interacting with those who share your condition and worldview.

The Homeodynamic Recovery Method Guidelines do not actually provide extra energy. The minimum amounts are set based on doubly labeled water clinical trials that confirm what non-restricting non-eating-disorder age and sex-matched cohorts eat daily on average.

You’ll find the data on actual food intake required for health and weight stability in the blog post Homeodynamic Recovery Method, Doubly-Labeled Water Method Trials and Temperament-Based Treatment.

The Basics

I have mentioned this in most other blog posts, but I’ll repeat it: bulimia has the same neurobiological underpinnings as anorexia. They are not two distinct conditions, no matter how much the symptom checklists in the DSM (Diagnostic and Statistical Manual for Mental Illness) say that they are. 1,2,3,4,5,6

Having now had the benefit of interacting with hundreds of patients with eating disorders, I have yet to come across a single instance of someone who binges in the absence of ongoing attempts at restriction*. 

62% of all patients who develop anorexia become bulimic within 8 years of the onset of the original condition, if remission eludes them. 7 These results make sense.

As the body is catabolizing itself to try to make up for energy deficits from dieting, it eventually will get to a place of having nothing left to burn. If you would like more background on the biology of catabolism check out this fairly short post: Extreme Hunger II: Profoundly Disturbing. The only way the body can turn things around after years of progressive cellular destruction is to demand food with increasing urgency.

Cycles of restriction and reactive eating that progress into cycles of restriction, reactive eating and subsequent purging (vomiting, laxative or diuretic abuse, and compensatory exercise) are all behaviors that stem from your ED-controlled mind being at war with your body. You want the body to win, btw. 

The "binges" are not the issue as that is the body demanding energy to rectify the damage associated with restriction. The issue is the endless attempts to eat less than what is really needed immediately after a reactive eating session.

Why do I call it reactive eating? Because the body is reacting to a severe internal energy deficiency that renders it incapable of supporting all the biological functions that keep you not only alive, but healthy as well.

Etymology of Binge

Etymology means the study of the history of words and their meaning.

The word “binge” presumably dates back to 1854 and referred to a bout of drinking. Binge was originally a Northampton dialect word meaning “to soak” (as in to soak a wooden vessel). 8

Not surprisingly, the use of the word “binge” to include food coincides with the introduction of standard sizes for clothing for women, right after World War. 9

You may have noticed in many of my posts I attempt to reinforce that our cultural assumptions are not as universal or as constant as we believe them to be.

Take a moment to think about the fact that a word you likely hear multiple times in a week never existed in relation to describing the consumption of food until we industrialized and standardized women’s clothing.

“…craving for food, preoccupation with eating and loss of control over food intake represent a natural psychobiological adaptation to sub-optimal weight and food deprivation.

Compulsive eating is therefore best understood in terms of a conflict between a biologically derived drive for food and a culturally derived drive for thinness. Both of these processes have their parallels in the maintenance of dependency disorders.

The crucial difference however is that the urge to eat is biologically adaptive, and recovery from compulsive eating depends upon relaxing restraint.” 10

The most tragic aspect of bulimia is that the entire framework of the condition, as it is defined in the health practitioner communities, is flawed. Almost all clinical trials identify remission for bulimia nervosa as the cessation of binges and purging. It sounds as though there is nothing wrong with that, right?

Streetlight Effect Again

A police officer sees a drunk stumbling around a streetlight presumably looking for something. The drunk informs the police officer that he has lost his wallet. The wallet is clearly not there, so officer asks the drunk if he is sure he dropped it here, and the drunk responds that it was likely “back there a ways”. “Why don’t you go there to look then?” the officer asks. The drunk replies, "This is where the light is.”

I have already referenced this parable in Anxiety Cannot Understand Logic and it is about looking for solutions where you may expect to find them, or where it appears easier to find them, rather than where they really reside.

When I scan countless non-evidence based inpatient and outpatient program offerings for those with bulimia across the globe, the dominant theme is always one of “normalizing eating behaviors” and “creating structure”. That sounds good at face value, but underlying these euphemisms is a broad cultural fear of “binge”.

Practitioners are as convinced as their patients that “binges are not normal”. I often quote Dr. Rebecka Peebles from a conference last year stating that health care practitioners specifically need to stop being afraid of what the eating disorder is afraid of—a brilliant but largely unapplied observation in treatment today.

Does The Danger Reside Where We Think?

I commented on a blog post on EDbites.com a while back on the topic of standing in the streetlight focused on managing the drive to binge rather than addressing the drive to restrict, and I’ll provide an edited version here:

Re-feeding in “a controlled way” is likely another facet of the same pathology that causes food to continue to be identified as a threat.

Yes I’ve read Tetyana Pekar’s blog post and her observations align with my understanding of eating disorders. An eating disorder is a deadly dance of anxiety modulation (or emotional regulation).

Emotional factors may indeed trigger a binge, but are those emotional factors wrong? Perhaps not. Perhaps those drives to eat are more capable of identifying energy deficiency on a systemic level (despite weight restoration)?

When a woman sits down with a tub of ice cream after her boyfriend breaks up with her, is that a binge? Let’s say it is for argument’s sake. Is that bad? Well she doesn’t logically need the energy I’m sure everyone would agree — she’s just sitting on the couch moping, right?

The majority of menstruating women “binge”, primarily on carbohydrate/fat rich foods, at least once a month and usually in the luteal phase. 11,12,13,14 This monthly binge does not impact optimal weight (they stay weight stable). It is thought that this behavior may modulate serotonin during this phase of the menstrual cycle.

What if the meme of a tub of ice cream to soothe a broken heart allows for real neurotransmitter modulation that actually results in feeling soothed? The brain is 4% of our body by weight and demands 20% of the energy we take in— it is too simplistic to relegate energy management in our bodies to the first law of thermodynamics while failing to incorporate the second law of thermodynamics; the fact that our energy system is open (not closed); and the fact that metabolic suppression can lead to a (short-term) energy surplus all while failing to provide adequate energy intake to support all living functions in the body. Quality of energy is not maintained, and how and where energy is degraded is the miracle of our body’s ability to maintain its optimal weight set point without our paltry logical interference.

If a brain affected by an eating disorder is understood to have, in some way, misidentified food as a threat, then the individual faces a torturous problem: not eating is not viable long term, but eating generates heightened anxiety (anxiety being the result of a threat response that is meant to trigger avoidance of the threat). Anxiety that triggers avoidance from a rustle in the bushes is a good survival technique, but when threats are misidentified, then avoidance itself becomes pathological.

Cycles of restriction/reactive eating and purging are the elaborate anxiety modulation techniques that tend to originate from an initial effort of restriction.

As Ms.Pekar pointed out, she often felt tremendously calm and ease after purging— and that is to be expected — it is reinforcing a maladaptive threat avoidance response.

I think it is unwise to assume that because “binges” are distressful to someone with an eating disorder that it is therefore unhealthy. What is objectively unhealthy is having food identified as a threat in one’s mind because it will involve a constant level of vigilance towards food consumption that will result in energy deficits even if they predominantly go unnoticed by both patient and professional alike.

When a schizophrenic becomes highly distressed because he is forced to enter a room with a computer, we may indeed remove the computer to help him, but we don’t make the leap of assuming that the computer is therefore “unhealthy” for him to experience or be near.

The only difference is that all of society is happy to accept the unsubstantiated belief that “food binges are bad” whereas we can instantly identify that the schizophrenic has misidentified the computer as a threat without batting an eye. And no, I do not hold that schizophrenia has much in common with eating disorders and I use the condition only as a parallel example.

I am actually coming to the conclusion that we may have to argue that eating disorders are actually normative in our society, as is people’s overall dissatisfaction with their bodies, because we cannot identify treating food as anything other than a threat on a society-wide scale in our culture today.

Who Is Right?

I don’t actually know who is right. I know that physicians and therapists with no personal history of eating disorders generally find nothing amiss in applying the Homeodynamic Recovery Method Guidelines in the treatment of bulimia as well as anorexia and all the other facets of eating disorders.

I also know that many practitioners with a history of eating disorders find the Homeodynamic Recovery Method Guidelines unacceptable.

And while it’s fine for me to suggest that fear of binges is not objectively dangerous or unhealthy, it is perhaps not fine for me to suggest that anyone with a chronic condition can necessarily adopt normative behaviors. 

Remission, to me, is not the cessation of maladaptive behaviors associated with the misidentification of food as a threat. It is not the cessation of restriction, binges, purging, compulsive exercise, or the maniacal attention to “clean” foods. 

Remission to me is the resumption of normative behaviors as though no chronic condition were present. It should be noted that remission in all other health conditions spans the reduction of symptoms (partial remission) to resumption of normative laboratory and observational results (full remission).

The bottom line is there are two kinds of remission and they are best represented in the following two links:

I hope that Carrie Arnold will not mind me using her post from last Christmas to make my point. Ms. Arnold is a former anorexic and I do not believe that she has experienced bulimia or cycles of restriction and reactive eating (as far as I know). However, her post below reflects what is identified as clinical remission from an eating disorder:

Holiday Survival ED Bites Style

By comparison, here is one of our member posts from Remission Accomplished:

Incredible. I can remember with shocking clarity the past Halloweens that centered around (TW) minimal eating during the day, lots of exercise, just so that I could eat that pre-planned candy bar.
This year? Lots of laughing, hugs, shrieks, candy, and food. Despite being in a short, sleeveless costume and having nothing but an unzipped fleece for warmth, I was only slightly cold in the absolutely frigid, raining, nasty, abominable-snowman-esque weather. I trick-or-treated a bit (yeah I'm a college student--What of it!?), and then my friends and I huddled up in front of a fire with hot chocolate and apple cider, traded candy, and definitely got chocolate-wasted!
I will never again take normalcy for granted. This was my first 'normal' holiday in a long time, and it was utterly priceless.
I hope all of you braving the wrath of Hurricane Sandy are doing okay! You all are in my thoughts.

SetFireToTheRain at Halloween

I know which version of remission I prefer, but it is not for me to say, as someone who has never had an eating disorder, what makes sense for you.

*I want to clarify that I have seen only three cases of those in active recovery who became intensely anxious and focused on eating enough food. In all three cases, the patients were under the age of 25 and living at home; there had been pre-existing diagnoses of various psychopathologies; they were fairly aggressively medicated with psychoactive drugs both prior and during the recovery effort; and key family members were unsupportive of the process of unrestricted eating in recovery.

The facets of anxiety on eating enough food involved panic if food was not readily at hand; hoarding and stealing food and eating in secret; and some elements of using food consumption as an expression of individuality and separation from parents (rebellion). All three switched out their psychotherapeutic practitioners and subsequently all three recovered from the compulsiveness and drive to avoid any period of not eating.

Three case studies do not a clinical trial make, but I did want to add these observations by way of complete disclosure.

1. Strober, Michael, Roberta Freeman, Carlyn Lampert, Jane Diamond, and Walter Kaye. "Controlled family study of anorexia nervosa and bulimia nervosa: evidence of shared liability and transmission of partial syndromes." American Journal of Psychiatry 157, no. 3 (2000): 393-401.

2. Milos, Gabriella, Anja Spindler, Ulrich Schnyder, and Christopher G. Fairburn. "Instability of eating disorder diagnoses: prospective study." The British Journal of Psychiatry 187, no. 6 (2005): 573-578.

3  Halmi, Katherine A., Suzanne R. Sunday, Michael Strober, Alan Kaplan, D. Blake Woodside, Manfred Fichter, Janet Treasure, Wade H. Berrettini, and Walter H. Kaye. "Perfectionism in anorexia nervosa: variation by clinical subtype, obsessionality, and pathological eating behavior." American Journal of Psychiatry 157, no. 11 (2000): 1799-1805.

4. Tozzi, Federica, Laura M. Thornton, Kelly L. Klump, Manfred M. Fichter, Katherine A. Halmi, Allan S. Kaplan, Michael Strober et al. "Symptom fluctuation in eating disorders: correlates of diagnostic crossover." American Journal of Psychiatry 162, no. 4 (2005): 732-740.

5. Castellini, Giovanni, Carolina Lo Sauro, Edoardo Mannucci, Claudia Ravaldi, Carlo Maria Rotella, Carlo Faravelli, and Valdo Ricca. "Diagnostic crossover and outcome predictors in eating disorders according to DSM-IV and DSM-V proposed criteria: a 6-year follow-up study." Psychosomatic Medicine 73, no. 3 (2011): 270-279.

6. Eddy, Kamryn T., David J. Dorer, Debra L. Franko, Kavita Tahilani, Heather Thompson-Brenner, and David B. Herzog. "Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V." American Journal of Psychiatry (2008).

7. Eddy, Kamryn T., Pamela K. Keel, David J. Dorer, Sherrie S. Delinsky, Debra L. Franko, and David B. Herzog. "Longitudinal comparison of anorexia nervosa subtypes." International Journal of Eating Disorders 31, no. 2 (2002): 191-201.

8. Online Etymology Dictionary

9. Research and Design in Historical Patterns

10. Wardle, Jane. "Compulsive eating and dietary restraint." British Journal of Clinical Psychology 26, no. 1 (1987): 47-55.

11. Barr, Susan I., K. Christina Janelle, and Jerilynn C. Prior. "Energy intakes are higher during the luteal phase of ovulatory menstrual cycles." The American journal of clinical nutrition 61, no. 1 (1995): 39-43.

12. Gong, Elizabeth J., Dominique Garrel, and Doris Howes Calloway. "Menstrual cycle and voluntary food intake." The American journal of clinical nutrition 49, no. 2 (1989): 252-258.

13. Tarasuk, Valerie, and George H. Beaton. "Menstrual-cycle patterns in energy and macronutrient intake." The American journal of clinical nutrition 53, no. 2 (1991): 442-447.

14. Bryant, Maria, Kimberly P. Truesdale, and L. Dye. "Modest changes in dietary intake across the menstrual cycle: implications for food intake research." British journal of nutrition 96, no. 05 (2006): 888-894.