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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.