Techniques 2: When finite energy goes up against drive to survive.

I realize that in my previous post I forgot to include a variation on all the anxiety behaviors around attempting to eat when an eating disorder runs the show.

Snarfing is to eat quickly. What about when you are snarfing your food so fast you risk choking and the emotional timbre is one of feeling monstrously out-of-control? Where’s the flight/fight/freeze reaction in those cases? Isn’t that just binge eating disorder?

Patrick Emerson:
Patrick Emerson:

As I’ve already mentioned, various monozygotic twin studies as well as Kamryn Eddy’s longitudinal study, confirm that almost 2/3 of patients who develop an eating disorder will shift the expression of the disorder from restriction towards cycles of restriction and reactive eating and, eventually, bulimic behaviors. 1

This crossover of symptoms occurred by year eight in the study conducted by Dr. Eddy and her colleagues. In Drs. Kaye, Bulik and colleagues’ study published in 2005, just shy of 40% of patients diagnosed with anorexia nervosa had developed bulimia nervosa by year five. 2

In yet another study conducted by Kamryn Eddy and her colleagues in 2008, they confirmed the majority of those with anorexia nervosa had crossed over to restriction and reactive eating cycles by year seven. 3

And as Dr. Stephen Wonderlich and his colleagues concluded in their study of 2009: The results of this article suggest that although there is generally progression from restrictor AN to binge/purge AN to BN in a sizeable number of patients, other crossover patterns can be seen as well and the amount of crossover is quite large. This suggests a lack of predictive validity for subtypes.” 4

I’ll be blogging in a lot more detail on Drs. Wonderlich and Peterson’s thorough presentation at UCSD Eating Disorders Conference of 2014 in the coming weeks and it will hopefully help clarify bulimia treatment options further as well as explain the new standalone binge eating disorder classification found in the DSM 5.

You won’t find a lot of research data just yet on why the majority with eating disorders shift from restriction, to cycles of restriction/reactive eating, and then to bulimic cycles. Perhaps this is because the reason is likely self-evident: the body is sufficiently depleted of energy that it mounts a counterattack to survive.

Avoiding food is a time-limited endeavor when it comes to long term survival. At the point at which the body has run out of both organs to catabolize (destroying cells as a way to release their energy reserves into the system at large) and biological systems to suppress and halt (such as reproductive functions), what’s left? It’s going to have to force the issue that energy must be returned to it. And that’s two very powerful systems that have to go head to head: the (in this case skewed) threat identification system and the basic survival system.

Once a patient has applied constant energy deficiencies long enough to have hit a critical point in overall survival, then there’s going to be obligatory surging towards food followed by equally intense pulling away from food.

The very first time someone who has been restricting finds she “just keeps going” when eating rather than being able to maintain the rigid restriction, then that post-eating-session timeframe is intensely distressful.

There is no equivalent analogy that does this justice but the experience would be something akin to having some terrifying compulsion to sit in a pit filled with venomous snakes or being forced to eat excrement. The disgust and threat factors are off the charts after eating has, by the patient's definition, gotten completely out of control.

Immediate compensatory behaviors are enacted to try to soothe that train-wreck’s worth of shattered sense of control. First up tends to be a re-commitment to return to so-called good, healthy and moderate eating behaviors (translation: under nourishment relative to energy requirements).

“…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…the urge to eat is biologically adaptive, and recovery from compulsive eating depends upon relaxing restraint.” 5

Energy depletion, like sleep, is cumulative. Invariably, the patient arrives at another point at which the survival system takes over and what she had planned to stick to veers into restitution being taken by the body for the re-adherence to restriction. Shame features prominently in the post-eating-session experience (see: Dialectical Behavior Therapy: Shame, Guilt and Emotional Distress).

As the new pattern of restriction and reactive eating see-saws back and forth, patients tend to veer into one of two dominant clusters of cognition and behaviors.

One set tend to end up in a sea of resonance. Resonance, in physics, refers to the reinforcement, prolongation or intensification of sound by reflection from a surface or by the synchronous vibration of a neighboring object. The more the body demands energy the more intense the efforts to reapply restriction become. Each eating session event generates even more intense compensatory behaviors to try to modulate severe anxiety. Now it’s hours and hours on the treadmill, abusing laxatives, purging, self-harm. Chaos. Every eating event involves a genuine and desperate re-commitment to “never let it happen again”.

The other set of patients attempt to apply dampening effect or rituals and post-hoc rationalizations to try to get out ahead of the chaos. These patients will re-orient towards delaying eating sessions with elaborate planning, shopping and designing of eating session contents in detail. They will make and edit lists of foods that will be part of the eating session. They will clear their schedule and create adequate alone time for both the eating session and post-eating-session compensatory behavior.

But they will self-identify all these behaviors as being solely oriented towards the compensatory behavior and the relief that those behaviors generate. They don’t identify the pre-restrictive behaviors as having anything to do with the reactive eating session. They believe themselves to be hooked on the post-eating compensatory behaviors and that the eating session is merely a vehicle for applying those compensatory behaviors.

However if you were forced to eat excrement, which is the deep level of distress and disgust a patient with an eating disorder inherently experiences eating outside of a rigid restrictive framework, but always knew that after the horrific event you would be able to cleanse in some meaningful way, then your entire focus would likely be to get to that cleanse as well.

The bedeviling element for those with restrictive/reactive eating symptoms (as well as restrictive/reactive eating/purgingsymptoms) is that if an eating disorder specialist merely takes the patient’s distress at face value, then everyone is in the weeds attempting to halt ‘binges’. If an eating session doesn’t occur, then there will be no cascade of shameful and distressing thoughts and feelings. as well as no dangerous or harmful compensatory behaviors. 

Sounds like a plan right? Yes, and then both the eating disorder specialist and the patient are trying to shoehorn the patient back into pure restrictive behaviors. And it’s not really possible to overstate the danger this creates for a patient that has likely already exhausted her body’s ability to survive further energy depletion.

And the snarfing? It’s getting through the exposure to the threat as quickly as possible. And it is also an expression of the body trying to get in as much desperately needed energy, given that inevitable food avoidance is just around the corner.

Is it important to slow down the pace of eating? Yes, somewhat and especially if the patient is at risk of choking due to the speed at which she is eating. But of the utmost importance, is to help the patient focus on an immediate return to adequate energy intake following a reactive eating session (what she terms a binge).

In reality she is not in a pit filled with vipers and nor is she eating excrement. It is why enhanced cognitive behavioral therapy (CBT-e) and integrated cognitive-affective therapy (ICAT) have solid clinical data to support their use in the treatment of restrictive/reactive eating cycles and bulimia nervosa. Patients are successfully guided, with these treatment modalities, through the process of identifying false beliefs. Beliefs such as mistaken concepts regarding adequate daily food intake to meet energy needs; or that reactive eating is excessive and a shameful lapse in control; or that the mood modulation achieved with the ritual of ‘binges’ and purging has nothing to do with the pre-binge state of energy depletion— all are addressed within CBT-e or ICAT.

I’ll talk much more about ICAT in my UCSD EDC 2014 review in the coming weeks.

As false beliefs are uncovered, then the patient is also encouraged to up her daily intake to the point where the survival-based necessity of reactive eating sessions diminishes because now the body is being adequately re-energized.

And that patient will hopefully find the ideas in Techniques: approaching the food, eating the food helpful in navigating through the distress and discomfort of allowing the body to dictate its own energy replenishment requirements.

1. 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.

2. Bacanu, SilviuAlin, Cynthia M. Bulik, Kelly L. Klump, Manfred M. Fichter, Katherine A. Halmi, Pamela Keel, Allan S. Kaplan et al. "Linkage analysis of anorexia and bulimia nervosa cohorts using selected behavioral phenotypes as quantitative traits or covariates." American Journal of Medical Genetics Part B: Neuropsychiatric Genetics 139, no. 1 (2005): 61-68.

3. 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).

4. Peat, Christine, James E. Mitchell, Hans W. Hoek, and Stephen A. Wonderlich. "Validity and utility of subtyping anorexia nervosa." International Journal of Eating Disorders 42, no. 7 (2009): 590-594.

5. Wardle, J. (1987). Compulsive eating and dietary restraint. British Journal of Clinical Psychology, 26(1), 47-55