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The Bulimic Brain

Jacky Duong has been fighting the urge to throw up since she was fourteen, and recent research suggests the battle is largely with her brain.

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The nagging impulse was urgent and familiar. It drew Jacky Duong into the brightly lit kitchen of her North Berkeley apartment, where she stood contemplating the fridge. Having recently returned from a Saturday night dinner at a friend's house, the 21-year-old Cal student was feeling pleasantly satiated — but not stuffed. She could certainly eat more. Should she do it?

Her parents would be horrified. So would her friends, and her therapist. But a voice in the back of her head, small and insistent, nudged her on. Be reckless, it said. Lose control. Give in. Duong tried to push the feeling down, but it wanted to come up. She thought about the tray of brownies, the leftover potato salad, and the Tupperware of curry she had made the night before. She thought about not thinking. Then, she opened the fridge.

Give in.

Duong doesn't give in as often as she used to. Like many other women (and men) in America, she's considered to be "recovering" from bulimia nervosa, having received extensive treatment and therapy, much of it at the Alta Bates eating disorder clinic in Berkeley. Her treatment has helped her shed much of the guilt and secrecy that comes with the behavior. Now, chatty, perceptive, and disarmingly sarcastic, she is able to relate her history with barely a trace of discomfort, gesturing with her hands over the half-eaten slice of pie that sat on the cafe table during a recent interview. At one point she even quipped, "You'd better watch out, because this pumpkin tart is coming right back up."

Still, after four years of therapy, her progress appears to be modest. She is able to resist the bingeing urge, she estimates, "maybe one out of five times. ... And when I do overcome the other side," she said, leaning forward, her teardrop-shaped eyes lined with kohl, "it's like an achievement — like I'm winning a battle."

But that battle may never be easy for Duong, and recent research at Stanford and Columbia universities is starting to shed light on the reasons why. Although much is still unknown about bulimia, recent studies seem to suggest that the fight Duong is waging is largely with her brain. As young women with bulimia grow older, destructive impulses like bingeing and purging may become more powerful while parts of the brain that govern impulse control may weaken. And according to the studies, the bulimic brain is more likely to succumb to a variety of self-destructive impulses, making the disorder a sort of psychological Hydra. Over time, these impulses may turn into compulsions, or bad habits, much like drug addiction. In other words, the young woman originally from a Southern California suburb may be fighting her demons for a long time.

For Duong, the binge-and-purge cycle is a seductive voice, one that has dug its way deep into her mind. "It subconsciously creeps up; it helps when you feel lonely, when you feel sad," she said, referring to her disorder as though it brings her relief at times. "It gives you something to do."

The voice has been inside her head for seven years, she said, stirring her latte. She says that as she struggles with the urge to eat and throw up, the tension mounts. She feels agitated, on edge. But when she finally decides she can no longer resist, "all the anxiety melts away."

Entering binge mode, as she calls it, is like going into a frenzy. The cognitive science major at UC Berkeley is drawn to the fridge like a child to a shop window laden with sweets. "At first it feels great, because you're distracting yourself like crazy. And then when you throw up, you're just like ... empty." She reformed her statement: "You do it to avoid feeling empty, but you just go back to the same spot."


Jacky Duong is a woman who is very aware of her appearance. She knows how to put an outfit together. At the moment, she's wearing brown boots over jeans and a waist-cinching plaid pea coat. Her short black hair catches the light. Judging by the way she holds herself, you might think she is someone who is comfortable with — even likes — the way she looks.

But growing up, her body was little more than a burden. At six years old, she says, she was acutely aware that she had begun to "chub up." She knew it because her mother reminded her often.

Her mother "had a lot of issues of her own," she said. "She would say things like, 'You're fat because you're ugly, just like your dad.' Then she would go crazy and beat the shit out of me."

Besides the physical abuse, Duong remembers being called names like "fat elephant" and squeezed into skimpy outfits for swim and ballet classes, where she felt vulnerable and exposed. "I was ashamed of myself, constantly," she recalled. "I had no self-esteem."

Before her sophomore year of high school, she took her dissatisfaction with her body into her own hands. She had seen an episode of 20/20 on girls who suffered from eating disorders, and it gave her the idea to purge. The first time, she did it in the shower.

"The chick on TV ended up in the hospital, but that didn't even occur to me," she said. "I just thought, 'That's a good idea.'"

Over that summer, she started running six miles a day and throwing up after every meal. "She looked really slim," recalled Yolanda Chan, another Cal student and one of Duong's close friends since fourth grade. "Not unhealthy, it was, like, skinny. She looked prettier too, because she got skinnier. Everyone was telling her that. I think she really liked it and she had more confidence."

Not only had Duong been throwing up and exercising, but she had also drastically cut her calorie consumption, often eating nothing more than a yogurt for lunch. By the start of school, she had lost twenty pounds. Her broad-boned, 5-foot-4 frame now held 121 pounds. Yet despite the praise she was getting, she was struggling with depression, and she was worried about the effects of her disease.

"I developed these really swollen cheeks — chipmunk cheeks — from throwing up constantly," she said. "My face looked like a melon. It bothered me, even though other things should have bothered me more. Like, my tongue would start bleeding, and the top of my mouth would kind of peel off, and I would have stomach pains, you know.

"But I didn't worry about that because it wasn't the external image," she continued. "It wasn't how I looked. I wanted to stop because of how I looked, not because I was destroying my enamel. I treated my body like shit because I felt like shit."

Even at her lowest weight, Duong still felt strangely alienated from her own body. "It was just something for other people to see," she said. "I never truly appreciated it. I don't think most women do."

During her junior year, a school nurse called Duong's home and told her parents she was having serious eating issues. Her parents sent her to a psychiatrist, who prescribed twenty milligrams of Prozac daily. They hovered over her while she ate, making sure she polished off all the rice in her bowl without throwing up. They even installed a padlock and alarm on the fridge, rigged to go off every time she opened the door.

"It was humiliating," she recalled.

Around the same time, Duong began giving in to another destructive impulse.


Imagine a sandcastle. It's your store of "cognitive resources" — roughly, your willpower. The tide is coming. The crashing waves represent the impulse you have to battle, whether it's the urge to binge-eat, throw up, whatever. If your castle is packed tight, with all the right channels and moats, chances are it will survive the deluge. But if it's weak or architecturally unsound, expect nothing more than a sodden wreck when the waters ebb.

This is the case in bulimia, said Dr. James Lock, director of the Child and Adolescent Eating Disorder Program at Stanford. Lock has worked with eating disordered youth at the Stanford clinic for the past nine years. In his work, he has observed in his patients a variety of behaviors typically classified under the heading of "impulse control" disorders: kleptomania, alcohol and drug use, compulsive gambling, sexual promiscuity, hot-headedness, and trichotillomania (chronic hair-pulling). In 2010, these observations led him to explore the question of impulsivity, with the hope that by locating the source of the trait, he could better understand how to fix it.

Eating disorders are traditionally considered to be a confluence of genetic factors, cultural and familial pressures, and the internalization of media images equating thinness with beauty. The average age of onset is twenty, though it increasingly affects younger girls.

But much about the disorder remains a mystery. Part of the reason is that it has been notoriously understudied, especially in young girls. Worldwide, there have been just two studies on bulimia in adolescent girls. And Lock's was one of the first to delve into the uncharted territory of the bulimic brain.

Lock began his research by giving bulimic, anorexic, and healthy adolescent girls a simple task. Presented with a stream of letters on a computer screen, the young girls had to press a button each time they saw a letter — but stop themselves if they saw the letter X. While they completed the task, he scanned their brain activity.

Lock found that bulimics had a harder time squelching their initial impulse to push the button when they saw the taboo letter. Their brains said no — but the castle had already fallen. He also found that compared to their peers, the bulimic girls showed higher activity in the nervous circuits of the frontal lobe responsible for impulse control. Their brains, in other words, appeared to be working overtime.

Lock also found that his subjects seemed to have developed compensatory measures to help overcome their impulsiveness. They fortified their faulty castles by recruiting other areas of the brain, possibly to help them resist pushing the X button. There was also increased activity in the hypothalamus, which regulates emotions. This might point to heightened stress levels during the task, Lock said.

Lock believes the findings could change the way the eating disorder is viewed, though he remains cautious. "What all of this suggests is that we need to look at the question of impulsivity as a characteristic that needs attention when you're looking at eating disorders that have bingeing and purging associated with them," he said. And while many physicians might already consider impulsive behaviors when treating eating disorders, "what is novel is showing it at the brain level," he explained.

Lock patterned his research after a study published the year before from Columbia University. And though his results differed from that one, the two together may provide insight into what happens in the brain when adolescent girls with bulimia become adult women.

The first time she stole something, Jacky Duong felt electrified. She was sixteen, walking down a store aisle with her mother. A box of candy caught her eye. She remembered that she had just eaten a sandwich, and wanted to keep bingeing. So she took the box, found a secluded aisle, unwrapped it, and devoured its contents on the spot. Of course, it wouldn't stay down for long.

Stealing opened new possibilities, Duong remembered thinking. If she could get a free lunch, what else could she get for free? In her mind, she saw the window display of a department store, illuminating the trendy clothes and sparkling jewelry that teenage girls covet. Before long she started swiping plastic rings, silk scarves, and designer boots. The things she stole all had one thing in common: They all fit in her purse.

The more Duong gave in to the urge to vomit, the more she felt the need to steal from stores. The two fed off each other. Soon she was taking jewelry she didn't need, clothes she didn't want. Stolen goods piled up in her closet until she was literally giving them away. But she couldn't stop. "It was empowering," she said. "I was invincible. I was, like, 'I can eat all the food I want and not get fat; I can get all the pretty things I want without paying.'"

To Duong, both of her urges represented a hunger for control — over her image, her appearance, and, ultimately, herself. "It stemmed from something deeper," she said.

Then once Duong entered college, the restrictions her parents placed on her eating and bingeing disappeared. Bulimia began taking up a disproportionate amount of her time. The turning point came during her second semester, when she was forced to quit the campus Taekwondo team because she was too weak to compete. Her grades had started slipping.

"I spent my entire fall semester staring at three walls — the stall of a bathroom," she said.

In February of her freshmen year, Duong realized that her eating disorder had gotten out of control. She withdrew from her classes to look for a recovery program.

The answer came while she was getting a blood test at a nearby medical center. A nurse asked her, as part of a routine survey, if she was having suicidal thoughts.

She was, she said.

She was sent by ambulance to a 75-hour holding station, then voluntarily enrolled in an inpatient-outpatient program at the Center for Anorexia and Bulimia at Alta Bates Summit Medical Center.

She had almost given up the fight.


The image the media paints of eating disorders is unflattering at best. It's portrayed as a Hollywood disease of decadence and superficiality, relegated to image-conscious dancers (think of films like Center Stage and Black Swan) and movie stars like Lindsay Lohan who "starve" for attention. Jacky's father calls bulimia "the queen's disease," because only the rich can afford to throw money down the toilet.

Similarly, shoplifting is viewed with strong disdain. Moreover, compulsive shoplifters know there can be a high price for their actions — imprisonment, fines, and public humiliation, to name a few. They don't need what they take, and many report guilt for their actions. So why do they keep doing it?

Dr. Rachel Marsh, a pediatric neuroimager who studies bulimia at Columbia University, was the first to try a brain-based impulse test to get to the root of the disorder in 2009. Like Lock, she believes the key to getting at the origin of the disease is to study how bulimia develops through adolescence. Also like Lock, she focuses on the frontostriatal circuits, the brain's centers for reward and impulse control.

Marsh, whose interest in eating disorder stems from her earlier work on Tourette's syndrome, compares the need to overcome the binge-purge impulse in bulimia to suppressing the "tic" in Tourette's: "It's the same way that a girl presented with a whole table of food needs to inhibit the impulse to eat it very quickly," she said. "They can do it — it's just very difficult."

Unlike Lock, Marsh is not a clinician — she studies brains, not patients. According to her, the frontostriatal circuits, which are mediated by chemicals including dopamine and serotonin, harden during adolescence — roughly the same time that an eating disorder sets in. "Probably these deficiencies [in brain circuits] allow these behaviors to crystallize into habits," Marsh said.

In her 2009 study, Marsh looked at adult women, and the results were different from what Lock found with adolescent girls. Her twenty bulimic patients had longer response times and made more errors on the test she administered. And while the bulimic teens that Lock studied showed lots of brain activity, suggesting a fierce battle inside their brains, the bulimic women that Marsh studied showed less activation in their frontal lobes.

Like so much about eating disorders, there may be many reasons for why Marsh and Lock's results were different. It could be that the task Marsh used was more difficult. But it could also be that her patients were older and had suffered from their eating disorders for longer, leaving more time for their brains to undergo changes. Perhaps their impulse control pathways were no longer capable of putting up the same resistance.

The results of the studies also suggest something more. If an impulse can harden into a habit, and a habit can turn into a compulsion, and a compulsion can serve as behavior that a user relies on to feel normal and in control, then perhaps researchers should be trying to understand this mysterious disease by viewing it through the lens of drug addiction, Marsh said. "Food, drugs, they're both rewards," she noted.

In fact, this way of thinking about eating disorders is an emerging trend in the field.


Greta Gliessner is a 37-year-old New Yorker who says she was addicted to bingeing and purging. In her late teens and early twenties, she used to drive to the grocery store to buy cartons of ice cream and bags of chips to binge on. She'd start before she made it home. At the height of her disorder, she would vomit thirty times a day.

"Even if I would just drink Diet Coke I would have to purge," she said. "That feeling of fullness is what I could not stand. It could be a salad, it could be a carrot; whatever it was, it was coming out."

The consequences of Gliessner's behavior also bring to mind a drug addict. "I lost everything," she said. "I was spending $100 a day on food. I pawned things, I stole things, I got kicked out of my apartment." When she ran out of money, she would use her parents' credit card number to order out.

But can someone really be addicted to bulimia?

Absolutely, said Billy Chen, a researcher at the National Institute on Drug Abuse in Maryland. Chen, who studies substance addiction, said any behavior that creates a reward system and provides its user with a feeling of release can turn into an addiction. That release can set up a pattern of using the behavior whenever the user feels bad. In this case: feel bad, binge, purge. Repeat.

As the theory goes, when we repeat certain behaviors — like bingeing, using drugs, or stealing to manage anxiety — we strengthen those neural pathways while weakening others. Bulimia, in fact, has already been shown to alter the same pathways that long-term drug use does: In the brains of recovering bulimics, serotonin no longer binds as effectively, UC San Diego researcher Walter Kaye found in a 2001 study.

In addition, one of the main factors in judging addiction is whether the user engages in what is known as automatic drug-seeking behavior — in the case of bulimia, obtaining food and eating it to get the "high."

Gliessner is writing a memoir about her experience, and runs a bulimia recovery blog, where she comments on portrayals of food and eating disorders in the media through the lens of her own experience. It's called, "Life With Cake."

She now works as a therapist at the Metropolitan Center for Mental Health, in the outpatient substance abuse program. She spent most of the intervening years in Florida, in rehab, therapy, and attending Overeaters Anonymous meetings. She uses her history of eating disorder to connect to her patients with drug problems — because, she says, the experience translates.

"It's all serving the same purpose," she said, "which is to fill some kind of spiritual void — an emptiness that you can't satiate in any other way.

"I was a junkie, but with food."


Heather Sutherland knows that there's more to an eating disorder than eating. She's a youthful eating disorder therapist with gray-blue eyes and a loud laugh — a laugh liable to reveal the flash of a silver tongue ring. As group therapy leader at Alta Bates, Sutherland worked with Duong for more than four months to help her shed her habits and confront her past.

The most common treatments for bulimia are anti-depressants, family therapy, and cognitive-behavioral therapy — a type of therapy that seeks to refocus distorted concepts of weight and then home in on common binge triggers, Sutherland said. Duong has undergone all of them. A rethinking of the disease, however, might point to different drugs, programs, or types of therapy as being more effective. Given the results of his latest study, James Lock is now working on a comprehensive comparison of different treatments, which he aims to publish in two years.

At Alta Bates, fixing bad eating habits is the program's first step. Most of the women who enter the clinic have been hospitalized due to their disorder or find themselves no longer able to function in daily life. Weak, emaciated, or suffering from other nutrition-related problems, their eating patterns are often the best indicator of their mindset. And that must be addressed before deeper work can be done.

"Food is core," said Sutherland, sitting in her office on Dwight Way. "To literally manipulate your body and your food — the one thing you really need to survive — that's pretty hard-core."

Duong recalled being monitored by nurses while she ate her meals. It's a prospect that, a year earlier, would have sent her into a panic. "But I was finally in that stage where I wanted to work on myself, so I cooperated."

As in many recovery programs, Sutherland's goal during group therapy is to locate the root of her patients' behaviors and make them aware of how they have become self-destructive. If their brains naturally lean toward impulsiveness, she hopes to train them to manage those impulses constructively.

She has a multi-layered approach. For instance, as one way to encourage reflection on the here and now, Sutherland, who is also a licensed art therapist, leads art and yoga therapy classes. And she doesn't hesitate to delve deeply — even painfully so — into patients' past histories of trauma and abuse.

But a big piece is simply being accountable. She starts by asking patients to recount their emotions and what they ate the night before. "They need to report specifically what happened, put it very out in the open," she said. "A lot of the time they've been so used to the secrecy around it that that in itself can be a relief."

Sutherland's approach can also apply to other behaviors, including shoplifting. It's about strengthening the castle walls — in other words, taking control of your actions by undoing destructive behavioral patterns, and, hopefully, building up more constructive alternatives. Moreover, it's about recognizing that bingeing and purging will cause damage in the longterm, even while it relieves the immediate anxiety.


Jacky Duong remembered writing in her journal the first thing she did when she got home from the Alta Bates clinic: She ate a spoonful of yogurt. "To eat a snack — this tiny morsel of food — it was ...." She struggled for an analogy. "It's as if you were paralyzed for a really long time, and suddenly, you twitched."

She also remembered the next time she passed by a clothing store window. She stopped to glance in. But she didn't feel the urge to enter the store, and stealing didn't sound like a thrill.

"When I started trying to take control of my life, I stopped everything else," she said. "You kind of walk by the pretty things and you're, like, 'I could take that ... or walk away.'"

She walked away.

There is a grieving process that occurs when an eating disorder is confronted and a patient must let go of the behaviors that previously imbued them with a sense of control. It's a process that can be painful, difficult, and disorienting, Sutherland said. "It's like it's your best friend," she explained. "It's always there for you. It doesn't talk back ... and you can always come back to it. It becomes your identity."

Duong's two-week stay at the clinic cost $74,000, most of which was covered by her health insurance. She still owes hundreds of dollars in co-pays, and thousands more for withdrawing from school. But her work with Sutherland also put her on the path to recovery, which neither antidepressants nor therapy alone could do.

She still struggles. Sometimes, she feels empty, and other times, it's as if she's returned to the same spot. She doesn't weigh herself. But she speaks regularly with a therapist, and she can sometimes beat the bingeing urge by exercising or surrounding herself with friends.

Though the taunting voice inside her head will always be there — Sutherland said an individual with an eating disorder deals with it forever — she is learning to live with it.

And perhaps, as researchers like Marsh and Lock continue to unlock the mysteries of the bulimic brain, others will have an easier time as well.


A New Openness? Bulimia is coming out of the closet, but the same can't be said for shoplifting.

In recent years, there's evidence that the American public is taking the issue of mental illnesses, including eating disorders, more seriously. According to a survey released in February by the National Eating Disorders Association, an advocacy group for eating disorders prevention, 57 percent of respondents were "fairly well educated" about eating disorders, and 82 percent viewed them as "mental or physical illness[es]." The survey involved 1,000 randomly selected adults and was conducted by the independent research firm American Viewpoint.

"It's a new day," said Lynn Grefe, CEO of the eating disorders association. "For too long people just didn't talk about [eating disorders]. The public looked at it like a lifestyle choice, like people chose to have an eating disorder, terrible things. You wouldn't say that to somebody with brain cancer."

Since its formation in 2010, the association has existed to remind the public that eating disorders are serious, life-threatening illnesses. In fact, they claim the highest death rate of any psychological illness — 10 to 20 percent of all individuals hospitalized for anorexia will die in the next ten to thirty years due to their disease. There appears to be a new openness in the air, said Grefe, pointing out that social stigma is a key reason that eating disorders have remained under the rug over the years.

But while behaviors like bulimia are now becoming better understood, stealing is still considered morally repugnant. A shoplifter told her group leader at the National Institute for Shoplifting Prevention — which runs the only national program for shoplifting recovery — "If I were an alcoholic and I told my friends I was seeking help for alcoholism, they would be proud of me. If I told my friends I was seeking help for a shoplifting addiction, they would look at me like I was a criminal."

Because of its stigma, it's difficult to know how widespread bulimia is. According to the Diagnostic Statistical Manual, the disease affects 1 to 2 percent of adolescent girls. But shoplifting can be even more covert. Though recovering bulimics may be willing to talk about their eating problems, many "suffer in silence" when it comes to taboo topics like shoplifting, according to Dr. Tony Paulson, co-author of the book, Why She Feels Fat and the director of a private recovery clinic in Sacramento. "I have yet to see a billboard promoting help for compulsive shoplifting," Paulson noted.

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