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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.