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Dying to be Thin
Ask the Experts
Answers from Dr. Craig Johnson, Set #3
Posted December 19, 2000
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Q: I began purging when I was 16 years old, after trying to restrict my diet didn't work. My bulimia lasted from 16 throughout college (I am now 24). Ever since then I have had extreme anxiety and suffer from panic attacks. My question is: There are periods of my life when I do not participate in purging, restricting, or laxative use (even though I still have low self-esteem thoughts), and when I go through periods of anxiety, the behaviors begin again. Is there such a thing as a "recreational bulimic?" I have been in therapy before but have never focused on this issue. What, if any, should be my next step? Thank you.

Anonymous from California

Johnson: Many, many, many people manifest signs of disordered eating at times of stress. It is important to remember that food is a universal pacifier. Most of us have had food placed in our mouths as children to sooth us or quiet us down. It is not surprising that we develop life-long tendencies to overeat during periods of uneasiness or when we are feeling lonely, bored, or angry. We have also learned that carbohydrates can create increased levels of serotonin, which has a tranquilizing effect. This is a similar neurochemical change that we try to accomplish with serotonin medications like Prozac, etc. Surprisingly, we have also learned that self-induced vomiting produces neurochemical changes that are calming, and that exercise creates neurochemical changes that help relieve depression and anxiety.

Consequently, when we see someone trying to solve problems by using these behaviors, there are two things we try to accomplish. First, can we intervene with medications and find a safer or more effective way to address depression and anxiety. Secondly, can we help the individual find other psychological coping strategies to help manage the depression, anxiety, and self-esteem issues.

Q: I am in need of a program that would monitor my daily eating habits and lead to the proper nutritional diet. I am presently bulimic when I am alone every other week. I binge and purge, binge and purge. I have never had the opportunity to develop proper eating techniques and have no idea of any inhome support groups in Canada that offer in care treatment, which I would like to enroll in to be able to be led by the hand to educate me and get me on the right nutritional program. I am 5' and 150 lbs. I have been a yo-yo dieter all my life and also taken ephedrine since I was 12 years old for diet control and energy. Please tell me what you think would be advisable. I was thinking of asking my doctor for media or that diet pill that is out now. Thank you for your time.

Anonymous from Ontario, Canada

Johnson: Approximately 40 percent of patients with eating disorders will also be struggling with obsessive-compulsive disorder (OCD). In fact, when we see these two disorders together we know that the OCD is the primary problem and that the disordered eating is mostly an extension of the OCD. We generally have to focus on solving the OCD through a combination of psychotherapy and medication first. If we don't solve the OCD, individuals will often "symptom substitute." This means that if we successfully intervene with their disordered eating they will develop obsessions and compulsions around other things like germs or whether the door is properly closed and locked. This treatment usually requires a professional that is skilled in treating both eating disorders and OCD.

Q: My daughter struggled with bulimia when she was in college. Two years have passed, and she is now married with an infant son. She is the happiest I have ever seen her. However, she is nursing and able to eat `normally' without gaining weight. How can I support her when she stops nursing? I am afraid she will struggle with her eating issues when she stops nursing. Thank you for your help.


Johnson: Most women stop their eating disorders during pregnancy. There are several explanations for this. For some they feel they have permission to gain weight and become larger. They feel temporary relief from having to look perfect, which includes being thin. Many report that this is the first and only time that they feel freedom from the tyranny of thinness. Unfortunately, the freedom does not last much beyond the delivery. Some, who struggle with profound feelings of shame and worthlessness, will take care of themselves for the sake of the baby, but will not extend this same level of care to themselves once the baby is born. This period of abstinence or recovery does create a window of opportunity for psychological work, so I would encourage you to encourage your daughter to pursue psychotherapy. It does become clear that she has the ability to not do the behaviors.

Q: My daughter is suffering from dual problems: bulimia and bipolar. We are trying to find treatment (in Northern VA) that will help stabilize her but have had limited success. She was in a hospital center for a short time and that helped, but she has since regressed. We've heard inpatient may not be as successful as outpatient care since the stay is short and folks backslide. Also, insurance coverage is limited and psychiatrists are overbooked. Is there no way to get comprehensive care in a relatively short time or will things just take years to resolve themselves?


Johnson: Many of the questions we have received are asking about how to access adequate treatment and what is the average course of illness. Unfortunately, it is currently very difficult for most people to access specialized treatment for most illnesses. Today, the expected length of stay for a psychiatric hospitalization is about four days. The necessary length of stay to minimally restore normal weight for patients with anorexia nervosa is about 60 days. Patients with more severe bulimia who have not responded to informed outpatient interventions often require stays in the 45-day range.

More complicated medical conditions and co-occuring psychiatric symptoms such as bipolar illness make the necessary length of stay even longer. As you can see, there is a significant discrepancy between the target length of stay of most managed care organizations and the reality of the illness. Many of these organizations will make an effort to accommodate specialized care because of the lethalness of the illness. However, many will not. The HMO's are usually the least flexible because they have fewer resources to work with. The resource issue is made even worse by the fact that there are far too few quality treatment centers. Waiting lists are often long, and families have to travel long distances, which makes family therapy difficult to accomplish. There are simply not good answers to these issues, and the issues are not particularly unique in our current heath-care system.

There are things you can do to lobby for care. Without a doubt the squeakiest wheels do get the most oil. Persistently present informed treatment options to your insurance group. Complain to your state insurance regulatory agency. Ask your employer to help with the insurance group. Appeal to your political representatives. Angry mothers and fathers make most politicians and administrators uncomfortable. I would also suggest that you contact Anorexia Nervosa and Associated Disorders in Chicago, IL, and Eating Disorders Awareness and Prevention in Seattle, WA. They have specific recommendations for families that are trying to access care.

The good news is that 75 percent of patients that are struggling with anorexia nervosa and bulimia will completely recover from the illness if they receive adequate care. The bad news is that for about 50 percent of the people who develop the illness, the length of time to recovery can be about five to seven years. However, 30 to 50 percent will be significantly improved or fully recovered within two years of receiving treatment.

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