Case Study: The Body That Kept the Score — PCOS, Insulin Resistance, and Childhood Emotional Neglect

Category: Case Studies | All Four Directions | Composite Clinical Case

DISCLAIMER: This is a composite fictional case study based on common clinical patterns observed across integrative and functional medicine practice. It does not represent any single real patient. All names, identifying details, and specific circumstances are invented. The clinical patterns, lab values, treatment protocols, and healing trajectories described reflect well-documented presentations in the literature and are intended for educational purposes.

---

Presenting Complaint

Mai, a 28-year-old Vietnamese-American woman, presented with concerns about weight she “cannot lose no matter what,” persistent cystic acne along her jawline and chin, and irregular menstrual cycles (occurring every 45-90 days, sometimes skipping months entirely). She had been diagnosed with PCOS (polycystic ovarian syndrome) at age 22 by her OB-GYN, who prescribed oral contraceptives and spironolactone. She took them for four years, during which her acne cleared and she had regular withdrawal bleeds (not true periods — the OCP suppresses ovulation and creates artificial bleeds). When she discontinued the pill at age 26 with the hope of eventually conceiving, everything returned: the acne, the irregular cycles, the weight gain — now worse than before.

Over the past two years, she had gained 35 pounds despite what she described as “trying everything”: caloric restriction (1,200 calories/day for months), keto diet (lost 10 pounds, then plateaued and felt terrible), intermittent fasting (16:8, which worsened her anxiety and binge-eating), and intense daily exercise (Orange Theory 5x/week). The weight sat stubbornly around her midsection and upper back — the classic insulin-resistant pattern.

Additional symptoms: fatigue (especially after meals), brain fog, mood swings (irritability and anxiety premenstrually — when periods occurred — and sometimes for no apparent reason), dark patches on neck and inner elbows (acanthosis nigricans), hair thinning on her scalp with simultaneously increased facial hair growth (peach fuzz becoming coarser on upper lip and chin), and a near-constant craving for carbohydrates and sweets that she described as “I feel like I’m addicted to sugar.”

She had also seen a dermatologist (prescribed tretinoin and clindamycin — temporary improvement), an endocrinologist (confirmed PCOS diagnosis, recommended metformin which she tried for 3 months but discontinued due to severe GI side effects), and a naturopath (who put her on a generic hormone-balancing supplement with unclear ingredients — no improvement).

The symptom that troubled her most was not the weight or the acne — it was the shame. “I hate my body,” she said in the first session, not meeting the practitioner’s eyes. “I’ve hated it since I was a kid.”

---

History

Medical History

Born full-term, vaginal delivery, breastfed for 3 months (mother returned to work). Childhood: frequent ear infections treated with multiple rounds of antibiotics. Menarche at age 11 (early — a risk factor for PCOS and insulin resistance). Periods were irregular from the start — never establishing a regular cycle before being placed on OCPs at age 16 for “regulation.” History of recurrent yeast infections (Candida — related to antibiotic history, insulin resistance, and OCP use). No surgeries. No significant injuries.

Family History

Mother: Type 2 diabetes (diagnosed at 45, currently on metformin and insulin), obesity, depression. Father: hypertension, fatty liver, “pre-diabetic” (currently on metformin). Maternal grandmother: Type 2 diabetes, died of stroke at 68 in Vietnam. Paternal grandmother: obesity, “hormonal problems” (never specified). Older brother: healthy but overweight. The metabolic picture was unmistakable: multigenerational insulin resistance running through both family lines, likely compounded by the dietary transition from traditional Vietnamese cuisine to the standard American diet after immigration.

Social History

Mai was born in San Jose, California. Her parents immigrated from Vietnam in the late 1980s and opened a nail salon — a business that consumed their entire lives. Mai described a childhood of physical presence but emotional absence: “My parents were always there, but they weren’t really there. They were working or they were exhausted from working. We didn’t talk about feelings. We didn’t talk about anything except grades and work.”

She was a quiet, overweight child who found comfort in food — specifically, the sweet Vietnamese desserts her grandmother would make when she visited, which became associated with the only warmth and attention she received. By age 10, she was sneaking food at night, eating in secret, and lying about what she had consumed. This pattern continued into adulthood.

She attended San Jose State University, graduating with a degree in accounting. She worked at a mid-sized firm, was competent at her job, and described her professional life as “fine.” She was single, had dated intermittently, but described a pattern of either choosing unavailable partners or sabotaging relationships when they became intimate. “I don’t want anyone to see me — like, really see me. Especially not my body.”

Emotional History

When asked about her emotional life, Mai became visibly uncomfortable. She described herself as “fine, usually” and then, after a silence: “I guess I’m kind of numb most of the time. Except when I eat — then I feel something.” She described episodes of binge eating 2-3 times weekly: purchasing large quantities of food (usually sweet pastries, bread, and chips), eating rapidly and alone, feeling a brief rush of pleasure followed by intense shame, and then restricting food the next day as penance. This cycle — restrict, binge, shame, restrict — had been active for approximately 16 years.

She had never been to therapy. She had never told anyone about the binge eating. The practitioner was the first person she disclosed this to, and she cried as she spoke.

Deeper exploration revealed: no overt abuse in childhood, but significant emotional neglect. Mai’s emotional needs — for comfort, validation, mirroring, co-regulation — were consistently unmet. Her parents provided food, shelter, education, and discipline, but not emotional attunement. In attachment terms, this is the avoidant-leaning neglect pattern: the child learns that emotional needs will not be met by others, so they must be met through alternative means. For Mai, food became the substitute attachment figure — the reliable source of comfort in a world where human comfort was scarce.

Spiritual History

Mai described herself as “not spiritual at all.” Her parents were nominally Buddhist but rarely practiced. She had no spiritual framework, no contemplative practice, and when asked about meaning or purpose, she shrugged: “I just try to get through the day.” Beneath the shrug was something more painful: a sense that her life lacked direction, that she was going through motions without knowing why.

---

Assessment Through Four Directions

Serpent / Rắn (South) — Physical Body

Mai’s physical presentation was a textbook case of metabolic dysfunction driven by insulin resistance. PCOS is not primarily an ovarian disorder — it is a metabolic-endocrine disorder in which insulin resistance is the central driver in approximately 70% of cases (Dunaif, 1997). Elevated insulin stimulates ovarian theca cells to produce excess androgens (testosterone, DHEA-S, androstenedione), which disrupt follicular development (causing the “polycystic” appearance on ultrasound — actually immature follicles that failed to ovulate), cause acne and hirsutism, promote abdominal fat deposition, and create a self-reinforcing cycle: insulin resistance → hyperinsulinemia → hyperandrogenism → abdominal obesity → worsened insulin resistance.

The acanthosis nigricans (dark skin patches) was a visible marker of severe insulin resistance — insulin acting on keratinocytes in skin folds.

Her history of early menarche, familial metabolic syndrome, childhood antibiotics (disrupting gut microbiome → metabolic consequences), and decades of hormonal contraceptives (which mask the underlying dysfunction without treating it) all contributed to the current picture.

The binge-restrict cycle was metabolically devastating: caloric restriction → cortisol elevation → blood sugar instability → intense carbohydrate cravings → binge → insulin spike → fat storage → shame → restriction. This cycle was not a failure of willpower. It was a predictable biochemical consequence of insulin resistance meeting emotional eating meeting chronic caloric restriction.

Jaguar / Báo (West) — Emotional Body

The emotional dimension was where the roots of Mai’s illness were most deeply buried. Childhood emotional neglect — the absence of something that should have been present — is harder to identify than overt abuse because there is no event to point to, no memory to process. It is the wound of omission: the comfort that never came, the emotional attunement that was never offered, the mirroring that the child needed but did not receive.

In IFS terms, Mai’s system had organized around a central Firefighter part — the Binge Eater — whose function was to manage unbearable emotional pain through the neurochemical relief of food (sugar triggers dopamine and opioid release in the nucleus accumbens, providing temporary analgesic relief from emotional distress; Avena et al., 2008). This Firefighter was not Mai’s enemy. It was the part of her that had been keeping her alive emotionally since childhood, the only reliable source of comfort in a world where human comfort was unavailable.

Behind the Firefighter was an Exile — a young part carrying the core wound of neglect: the belief that she was fundamentally unlovable, that her needs were burdensome, and that her body was the evidence of her failure. The body shame was not vanity — it was the externalization of a deep internal wound. “I hate my body” really meant “I hate myself for needing what I needed and never receiving it.”

A Manager part — the Restricter/Controller — attempted to manage the Firefighter through willpower, diet rules, and exercise punishment. The Manager and Firefighter were in perpetual civil war, each triggering the other in an exhausting cycle that consumed enormous psychological energy.

Hummingbird / Chim Ruồi (North) — Soul

At the soul level, Mai was living a life that was not hers. The accounting career was chosen for parental approval and financial security, not from soul calling. The absence of meaningful relationships (romantic or platonic depth) left her isolated. The numbness she described — feeling nothing except during binges — was the soul’s starvation signal: without purpose, without genuine connection, without creative expression, the soul withdraws its vitality.

The cultural dimension was also relevant: Mai existed in the liminal space between Vietnamese identity and American identity, fully belonging to neither. Too American for her parents’ world (she didn’t speak Vietnamese fluently, didn’t cook traditional food, didn’t attend temple), too Vietnamese for the American world she moved through (the expectations, the family obligation, the immigrant guilt). This identity liminality contributed to the fundamental disconnection from self that expressed itself through food.

Eagle / Đại Bàng (East) — Spirit

The spiritual direction was, at intake, essentially dormant. Mai had no witness consciousness — no capacity to observe her own patterns from a place of compassion rather than judgment. She was completely fused with her thoughts (“I’m disgusting,” “I have no willpower,” “Something is wrong with me”) and had no framework for understanding these as thoughts rather than truths. The absence of spiritual ground left her at the mercy of every internal storm, with no anchor of awareness to hold her steady.

---

Testing & Diagnosis

Functional Medicine Laboratory Workup

Hormonal Panel:

• Total testosterone: 68 ng/dL (female range: 15-70; high-normal, functionally elevated)
• Free testosterone: 8.2 pg/mL (female range: 0.2-5.0) — elevated
• DHEA-S: 428 mcg/dL (female range: 65-380) — elevated
• SHBG (sex hormone-binding globulin): 22 nmol/L (optimal: 60-80) — critically low (insulin suppresses SHBG production by the liver, freeing more testosterone to act on tissues — this is the mechanism by which insulin drives PCOS)
• Androstenedione: 3.8 ng/mL (range: 0.7-3.1) — elevated
• LH: 14.2 mIU/mL
• FSH: 5.1 mIU/mL
• LH:FSH ratio: 2.8:1 (normal: ~1:1; elevated ratio is characteristic of PCOS)
• Estradiol: 42 pg/mL (low — consistent with anovulation)
• Progesterone (Day 21 equivalent): 0.8 ng/mL — confirms anovulation (ovulatory progesterone should be >10 ng/mL)
• AMH (anti-Mullerian hormone): 8.2 ng/mL (elevated — consistent with high antral follicle count in PCOS)
• Prolactin: 18 ng/mL (normal — rule out prolactinoma)

Metabolic Panel:

• Fasting glucose: 98 mg/dL (pre-diabetic range begins at 100; she is at the threshold)
• Fasting insulin: 24.3 uIU/mL (optimal: <7) — severely elevated
• HOMA-IR: 5.87 (optimal: <2.0) — severe insulin resistance
• HbA1c: 5.6% (pre-diabetic range: 5.7-6.4%; at the threshold)
• 2-hour glucose tolerance test: 156 mg/dL at 2 hours (pre-diabetic: 140-199) — impaired glucose tolerance confirmed
• Triglycerides: 188 mg/dL (optimal: <100)
• HDL: 38 mg/dL (optimal: >60) — low
• LDL: 142 mg/dL (borderline)
• Triglyceride:HDL ratio: 4.9 (optimal: <2.0 — this ratio is the best surrogate marker for insulin resistance)
• ALT: 48 U/L (elevated — suggests early non-alcoholic fatty liver disease, NAFLD)
• GGT: 52 U/L (elevated — liver stress)
• Uric acid: 6.8 mg/dL (elevated — fructose metabolism, insulin resistance marker)

Inflammatory Markers:

• hs-CRP: 4.2 mg/L (optimal: <1.0) — significant systemic inflammation
• Homocysteine: 9.8 umol/L (mildly elevated)
• Ferritin: 142 ng/mL (in the context of inflammation, ferritin rises as an acute phase reactant — does not necessarily reflect iron status)

Nutrient Status:

• Vitamin D, 25-OH: 18 ng/mL (deficient — <30 is insufficient, <20 is deficient)
• Magnesium RBC: 4.2 mg/dL (low-normal; optimal >5.0)
• Zinc: 62 mcg/dL (low-normal; optimal: 80-120)
• Chromium: low-normal
• Omega-3 Index: 3.8% (optimal: 8-12%) — severely depleted

Stool Analysis (GI-MAP):

• Elevated Candida albicans
• Reduced microbial diversity
• Low Akkermansia muciniphila (associated with insulin resistance when depleted; Depommier et al., 2019)
• Low Lactobacillus species
• Elevated beta-glucuronidase: 3,842 units (elevated — this bacterial enzyme deconjugates estrogens in the gut, recycling them back into circulation and disrupting the estrobolome, the collection of gut bacteria that regulate estrogen metabolism)
• Secretory IgA: low
• Zonulin: mildly elevated

TCM Assessment

Tongue: swollen, pale with a thick greasy white-yellow coat (Phlegm-Damp with underlying Spleen Qi Deficiency) Pulse: slippery, deep, and weak at the Kidney position Pattern: Kidney Yang Deficiency + Spleen Qi Deficiency + Phlegm-Damp Accumulation + Liver Qi Stagnation

In TCM, PCOS is classically understood as Phlegm-Damp obstructing the Chong and Ren channels (the extraordinary meridians governing reproduction), with an underlying root of Kidney Yang deficiency (the Kidney in TCM governs reproduction, bone, and the fundamental vitality of the organism). The Spleen fails to transform and transport fluids (Spleen Qi Deficiency), creating Damp accumulation (the weight, the foggy thinking, the sluggish digestion). The Liver Qi stagnation reflects the emotional suppression and frustration.

Somatic Assessment

Body posture: rounded shoulders, collapsed chest (protective posture — guarding the heart center). Held tension in the belly — when asked to place her hand on her stomach, she recoiled. Described her belly as “the part of me I hate the most.” Breathing was shallow and chest-dominant. During the assessment, when asked to simply feel her body without judgment, she dissociated — eyes glazed, attention left the room. This is a classic trauma response: the body is not safe to inhabit, so consciousness leaves.

---

Treatment Plan

Phase 1: Metabolic Rescue (Months 1-3) — Serpent Priority

The immediate priority was addressing the severe insulin resistance, which was the biochemical engine driving the entire PCOS picture.

Insulin Sensitizing Protocol:

• Berberine: 500mg 3x daily with meals (comparable to metformin for glucose reduction without the GI side effects; Yin et al., 2008 demonstrated non-inferiority to metformin for Type 2 diabetes. In PCOS specifically, berberine has been shown to reduce testosterone, improve insulin sensitivity, and promote ovulation; Wei et al., 2012)
• Myo-inositol: 4g daily + D-chiro-inositol: 100mg daily (40:1 ratio, matching the body’s natural ratio. Myo-inositol is an insulin sensitizer that has been shown in multiple RCTs to improve ovulation, reduce androgens, lower insulin, and restore menstrual regularity in PCOS; Unfer et al., 2012)
• Chromium picolinate: 1,000mcg daily (improves insulin receptor sensitivity; a meta-analysis by Fazelian et al., 2017 showed significant reduction in fasting insulin and HOMA-IR in PCOS)
• Alpha-lipoic acid: 600mg daily (insulin sensitizer, antioxidant, liver support)
• NAC (N-acetylcysteine): 1,800mg daily in divided doses (reduces androgens, improves insulin sensitivity, supports glutathione production for liver detox, and has been shown comparable to metformin for PCOS in some trials; Badawy et al., 2007)

Anti-Inflammatory & Nutrient Protocol:

• Omega-3 (EPA/DHA): 3g daily (reduce inflammation, improve insulin sensitivity, lower triglycerides)
• Vitamin D3: 5,000 IU daily + K2 (MK-7) 100mcg (target: 50-80 ng/mL; vitamin D deficiency is present in 67-85% of PCOS patients and correlates with insulin resistance severity; Irani & Merhi, 2014)
• Magnesium glycinate: 400mg at bedtime (cofactor for insulin signaling, calms nervous system)
• Zinc picolinate: 30mg daily (reduces androgens, supports immune function, improves acne)
• Spearmint tea: 2 cups daily (specifically anti-androgenic — reduces free testosterone; Grant, 2010)

Dietary Approach (NOT Restriction):

• Explicitly: no caloric restriction. No counting calories. This was a radical intervention for Mai, whose entire relationship with food was organized around restriction and punishment.
• Focus: blood sugar stabilization. Protein and fat at every meal and snack. Minimum 30g protein at each meal. Complex carbohydrates only (no refined flour, no added sugar). Abundant non-starchy vegetables. Healthy fats: avocado, olive oil, nuts, seeds, fatty fish.
• Meal timing: 3 meals + 1-2 snacks. No intermittent fasting (contraindicated in her metabolic and psychological state). Eat within 1 hour of waking.
• Vietnamese food integration: phở with extra protein and vegetables, canh (clear Vietnamese soups rich in vegetables and bone broth), gỏi (Vietnamese salads), steamed fish with ginger — emphasizing that her cultural cuisine, prepared traditionally, was inherently anti-inflammatory and blood sugar supportive. The problem was not Vietnamese food. The problem was the Americanization of the Vietnamese diet.

Gut Protocol:

• Candida treatment: Saccharomyces boulardii 500mg 2x daily + oregano oil 200mg 2x daily for 6 weeks
• Comprehensive probiotic: focus on Lactobacillus and Bifidobacterium species, 100 billion CFU daily
• Prebiotic fiber: 10g daily (supporting Akkermansia and beneficial flora)
• Calcium-D-glucarate: 500mg 2x daily (supports estrogen detoxification via glucuronidation, counteracting elevated beta-glucuronidase)

Liver Support (addressing elevated ALT/GGT and fatty liver):

• Milk thistle (silymarin): 600mg daily
• NAC (as above — dual purpose)
• Broccoli sprout extract (sulforaphane): 500mg daily (Phase 2 liver detoxification support)

Exercise Shift:

• Stop Orange Theory immediately (high-intensity exercise in severe insulin resistance with HPA dysfunction increases cortisol, worsens insulin resistance, and triggers compensatory eating)
• Replace with: walking 30-40 minutes daily (the single most insulin-sensitizing exercise — skeletal muscle contraction activates GLUT-4 transporters independent of insulin; Richter & Hargreaves, 2013), resistance training 3x weekly (building muscle mass increases insulin sensitivity at rest), and gentle yoga 2x weekly

Phase 2: Emotional Excavation (Months 3-8) — Jaguar Priority

IFS Therapy (Weekly):

The IFS work began cautiously. Mai’s system was highly defended — the parts that had protected her through decades of emotional neglect were not going to step aside easily.

Month 3-4: Meeting the Manager (The Controller) The first part to emerge was the Controller — the part that counted calories, set food rules, exercised punitively, and maintained the illusion of control. This Manager believed that if Mai could just be thin enough, disciplined enough, perfect enough, she would finally be worthy of love. Its mantra: “If you could just control yourself, everything would be fine.” The therapist helped Mai’s Self approach the Controller with curiosity rather than judgment: “What are you afraid would happen if you stopped controlling?” The Controller’s answer: “She would fall apart. She would eat everything. She would become her mother.” The fear of becoming her mother — diabetic, obese, depressed — was one of the Manager’s deepest motivations.

Month 4-5: Meeting the Firefighter (The Binge Eater) With the Controller’s cautious permission, the Binge Eater was approached. This part was younger, more primal, more desperate. It did not respond to logic. It responded to feeling. When asked what it provided, it said (through Mai’s tears): “I give her the only love she knows how to receive.” The Binge Eater carried the function of the absent mother — providing comfort, warmth, fullness in a body and psyche that were chronically empty. The therapeutic work was not to eliminate this part but to honor its function while finding other ways to meet the need it served.

Month 6-8: The Exile — Little Mai The deepest work. The exile was approximately 4 years old — a girl sitting alone in an empty nail salon after hours, waiting for her parents to finish work, eating leftover bánh from the shop refrigerator because there was no one to hold her. The core wound: “I am alone. No one is coming. Food is the only thing that comes when I need it.”

The unburdening of this exile — the IFS process in which the exile releases the beliefs and emotions it has been carrying — was the single most significant therapeutic event of the entire treatment. Mai sobbed through the session, and in the days following, reported something she had never experienced: she forgot to eat a snack, not from restriction but from genuine absence of the compulsive drive. The Firefighter, with the exile witnessed and held, no longer needed to perform its function with the same intensity.

Body Image / Somatic Work:

• Somatic Experiencing sessions (biweekly): learning to inhabit the body she had abandoned. Starting with neutral body regions (hands, feet) and gradually extending awareness toward the belly and torso. The instruction: “You are not required to love your body right now. You are invited to feel it.”
• Mirror work (introduced at month 5): standing before a mirror and practicing neutral observation rather than judgment. Not affirmations (“I am beautiful”) — which her system rejected as false — but observation: “This is my arm. It works. It carries things.”
• Introduced the concept of body neutrality as a stepping stone to body acceptance: the goal was not to love her body overnight, but to stop being at war with it.

Phase 3: Soul Reclamation (Months 6-10) — Hummingbird Priority

Cultural Identity Work:

• Mai began exploring what it meant to be Vietnamese-American — not the sanitized version her parents presented (work hard, be quiet, succeed) nor the stereotyped version American culture offered, but her own version.
• She started cooking traditional Vietnamese recipes from her grandmother’s memory — not for weight loss, not for health, but as a soul practice. The act of making phở from scratch — the 12-hour bone broth, the careful charring of ginger and onion, the aromatic spice sachet — became a meditation, a reconnection with lineage, a form of self-nourishment that was not destructive but creative.
• She began learning Vietnamese language with more commitment, attending community events, and reconnecting with her cultural identity.

Creative Expression:

• Mai discovered pottery — working with clay became a somatic-soul practice. Shaping something with her hands, making something imperfect and beautiful, was a direct counter-narrative to the perfectionism that had driven her eating disorder. Pottery does not allow control. The clay has its own intelligence. Learning to collaborate with material rather than dominate it was therapeutic at every level.

Narrative Reframing:

• The old story: “I am broken. My body is evidence of my failure. I am my mother’s fate.”
• The new story (emerging, not imposed): “I am a woman learning to nourish herself in all the ways she was never taught. My hunger is not shameful — it is the proof that I am alive and that I need. The women in my family survived on strength alone. I am learning to also survive on tenderness.”

Phase 4: Awakening Awareness (Months 8-12) — Eagle Priority

Mindfulness-Based Eating Awareness Training (MB-EAT):

• Jean Kristeller’s protocol: a meditation-based approach to eating disorders that combines mindfulness meditation with specific practices for eating awareness (hunger/satiety recognition, taste satiety, emotional vs. physical hunger differentiation). Research demonstrates significant reduction in binge eating frequency and severity (Kristeller & Wolever, 2011).
• This was not introduced until Month 8 because earlier introduction would have been co-opted by the Controller as another tool for restriction. By Month 8, sufficient IFS and somatic work had been done to create safety for this practice.

Meditation:

• Began with body scan meditation (10 minutes daily) — learning to rest attention in the body without fleeing
• Progressed to breath awareness (15 minutes daily)
• The meditation practice served a dual function: developing witness consciousness (Eagle) and continuing the somatic reconnection (Serpent/Jaguar)

Loving-Kindness (Metta) Practice:

• Specifically targeting self-compassion. The instruction: “May I be free from suffering. May I be at peace. May I learn to nourish myself with kindness.” This practice directly addressed the core wound of neglect: offering to herself the tenderness that was never offered by her caregivers.

---

Timeline & Progress

Month 1-2

• Began berberine, inositol, and full supplement protocol
• Shifted diet to blood-sugar-stabilizing approach (not restriction)
• Stopped Orange Theory; began walking and resistance training
• Energy improved within 2 weeks (blood sugar stabilization effect)
• Cravings reduced approximately 40% by end of Month 2 (berberine + inositol + protein at meals)
• Binge frequency: still 2-3x/week but intensity reduced
• Acne: no change yet (hormonal acne takes 3-6 months to respond)
• Emotional state: relief mixed with anxiety about the new approach

Month 3

• Repeat fasting insulin: 18.2 uIU/mL (down from 24.3)
• HOMA-IR: 4.2 (down from 5.87 — improving)
• Weight: lost 6 pounds without caloric restriction
• Began IFS therapy — meeting the Controller
• Binge frequency: 1-2x/week
• First period in 8 weeks — light but present

Month 4-5

• IFS: meeting the Binge Eater Firefighter — emotional intensity increased during this phase
• Binge frequency: temporary increase to 2-3x/week as emotional material surfaced (this is normal and expected during deep emotional work — parts that have been suppressed will initially escalate before they settle)
• Acne beginning to improve — fewer new cysts, existing ones resolving faster
• Period at 38-day cycle (shortening)
• ALT normalizing: 32 U/L (down from 48)
• Vitamin D: 38 ng/mL (responding to supplementation)

Month 6

• Breakthrough month. IFS exile work — the unburdening of Little Mai
• Binge frequency dropped to 1x/week, then 1x in 2 weeks
• “Something shifted — I don’t feel the same hunger. It’s like the hole is smaller.”
• Repeat labs: Fasting insulin: 12.8 uIU/mL, HOMA-IR: 3.0, Free testosterone: 5.4 pg/mL (down from 8.2), SHBG: 38 nmol/L (up from 22), HbA1c: 5.3%, Triglycerides: 128 mg/dL
• Weight: total loss of 14 pounds
• Period at 33-day cycle
• Began Vietnamese cooking practice and cultural reconnection
• Started pottery class

Month 8

• Acne: 80% cleared. Jawline breakouts rare. Skin tone evening out.
• Facial hair growth slowing (reduced androgen activity)
• Began MB-EAT mindfulness eating practice and meditation
• Binge episodes: approximately 1x/month, less intense, shorter duration, followed by self-compassion rather than shame
• Period: 30-day cycle for two consecutive months
• Began feeling “at home in my body for the first time” — could place hand on belly without recoiling

Month 10

• Repeat comprehensive labs: Fasting insulin: 8.4 uIU/mL, HOMA-IR: 1.9 (normalized), Free testosterone: 3.8 pg/mL (normal), SHBG: 52 nmol/L, Total testosterone: 42 ng/dL (normal), DHEA-S: 320 mcg/dL (normalized), HbA1c: 5.1%, Triglycerides: 92 mg/dL, HDL: 52 mg/dL, ALT: 22 U/L (normal), hs-CRP: 1.2 mg/L
• Weight: total loss of 28 pounds. Body composition dramatically shifted — visible muscle tone from resistance training.
• Acanthosis nigricans fading (insulin resistance resolving)
• Period: regular at 28-30 days for 4 consecutive cycles

Month 12

• Progesterone (Day 21): 14.2 ng/mL — ovulation confirmed for the first time in documented history
• Ovulation confirmed by basal body temperature tracking and ultrasound
• Binge eating: effectively resolved. Occasional emotional eating (once or twice monthly) managed with mindfulness and self-compassion rather than escalating to binge-restrict cycle
• Weight stable at 30-pound loss from baseline
• Acne: clear, with rare hormonal breakout managed with topical zinc
• Meditation practice: daily, 15-20 minutes
• Described the transformation: “I used to think the problem was my body. Now I understand the problem was that nobody ever taught me how to live in it.”

---

Key Turning Points

Turning Point 1: The End of Restriction (Month 1)

Paradoxically, the most powerful physical intervention was permission to eat. When Mai was told “You will not restrict. You will eat three meals and snacks. You will not count calories” — she initially panicked. The Controller part was terrified. But within two weeks, the blood sugar stabilization from adequate protein and the insulin-sensitizing supplements reduced the biochemical drive to binge more effectively than any amount of willpower ever had. The binge-restrict cycle cannot be broken from the restriction end — it must be broken from the nourishment end.

Turning Point 2: The Exile Unburdening (Month 6)

The IFS work with Little Mai was the emotional fulcrum of the entire case. When the 4-year-old exile was witnessed, held, and unburdened of the belief that she was alone and unlovable, the compulsive drive to eat for comfort lost its emotional fuel source. The Binge Eater Firefighter did not disappear — it simply no longer needed to work overtime. This is the difference between behavioral management (white-knuckling through cravings) and systems healing (addressing the wound that creates the craving).

Turning Point 3: Vietnamese Cooking as Medicine (Month 6-8)

The reconnection with traditional Vietnamese cuisine was simultaneously Serpent (nutrient-dense, anti-inflammatory food), Jaguar (healing the cultural wound of disconnection), and Hummingbird (reconnecting with lineage and identity). When Mai made her grandmother’s phở recipe for the first time, she wept — not from grief but from a sense of coming home. Food, which had been her captor, became her teacher.

Turning Point 4: Ovulation (Month 12)

The return of ovulation was the body’s declaration that it felt safe enough to reproduce — that the metabolic, hormonal, and emotional environment had shifted from survival mode to thriving mode. In functional medicine terms: insulin normalized, androgens normalized, hypothalamic-pituitary-gonadal axis restored. In Four Directions terms: the Serpent was nourished, the Jaguar was heard, the Hummingbird had direction, and the Eagle was present. The body, in its intelligence, said: “Now.”

---

Where Single-Direction Treatment Failed

Serpent alone (metabolic treatment without emotional work): Berberine, inositol, and dietary changes would have improved lab values — but without addressing the binge eating pattern driven by childhood neglect, the metabolic improvements would have been repeatedly undermined by episodes of metabolic disruption. The biochemistry cannot stabilize when the behavior is driven by unresolved emotional wounds.

Jaguar alone (therapy without metabolic intervention): IFS and somatic work would have produced emotional insight and healing — but without insulin sensitizers, nutrient repletion, and gut repair, the biochemical drivers of cravings (insulin spikes, blood sugar crashes, neurotransmitter depletion) would have continued to overwhelm psychological gains. You cannot therapy your way out of insulin resistance.

Behavioral approaches alone (diet and exercise): This is what Mai had been doing for 16 years — and it made her worse. Willpower-based approaches to eating disorders in the context of insulin resistance and childhood trauma are not only ineffective; they are iatrogenic. They reinforce the shame cycle, strengthen the Controller part, and provoke the Firefighter into escalation.

Medication alone (metformin, OCPs, SSRIs): The conventional approach manages symptoms without addressing any root cause. Metformin improves insulin numbers; OCPs create artificial cycles that mask dysfunction; SSRIs may reduce binge frequency but do not heal the wound driving the behavior. When medications are discontinued, everything returns — as Mai experienced when she stopped OCPs.

---

Lessons & Principles

1. PCOS is a metabolic disorder, not an ovarian disorder. The ovaries are downstream. Insulin resistance is upstream. Treating the ovaries (with OCPs) while ignoring the insulin resistance is like treating a fever with ice packs while the infection rages.

2. Binge eating is a symptom, not a character flaw. It has neurochemical drivers (insulin resistance, blood sugar instability, dopamine dysregulation) AND emotional drivers (attachment wounds, neglect, unmet needs). Treatment must address both simultaneously.

3. The restrict-binge cycle is a biochemical trap. Caloric restriction elevates cortisol, destabilizes blood sugar, depletes serotonin, and increases ghrelin. The binge is not the failure of the diet — it is the biological consequence of the diet. Breaking the cycle begins with adequate nourishment, not more restriction.

4. Emotional neglect is as damaging as emotional abuse — and harder to identify. Mai had no traumatic “event” to process. The wound was the absence of attunement, not the presence of harm. This makes it invisible to trauma frameworks that look for specific incidents.

5. Cultural food wisdom is medicine. Traditional Vietnamese cuisine — based on bone broth, fermented foods, fresh herbs, balanced flavors, and communal eating — is inherently therapeutic. The metabolic epidemic in Vietnamese-American communities is not caused by Vietnamese food. It is caused by the loss of Vietnamese food traditions and their replacement with the standard American diet.

6. The body keeps the metabolic score. Just as van der Kolk documented the body keeping the trauma score, the metabolic system keeps score of every unprocessed emotion, every cortisol surge, every insulin spike. The lab values are the body’s testimony.

---

References

• Avena, N. M., Rada, P., & Hoebel, B. G. (2008). Evidence for sugar addiction: Behavioral and neurochemical effects of intermittent, excessive sugar intake. Neuroscience & Biobehavioral Reviews, 32(1), 20-39.
• Badawy, A., State, O., & Abdelgawad, S. (2007). N-Acetyl cysteine and clomiphene citrate for induction of ovulation in polycystic ovary syndrome. Acta Obstetricia et Gynecologica Scandinavica, 86(2), 218-222.
• Depommier, C., et al. (2019). Supplementation with Akkermansia muciniphila in overweight and obese human volunteers: a proof-of-concept exploratory study. Nature Medicine, 25(7), 1096-1103.
• Dunaif, A. (1997). Insulin resistance and the polycystic ovary syndrome: Mechanism and implications for pathogenesis. Endocrine Reviews, 18(6), 774-800.
• Fazelian, S., et al. (2017). Chromium supplementation and polycystic ovary syndrome: A systematic review and meta-analysis. Journal of Trace Elements in Medicine and Biology, 42, 92-96.
• Grant, P. (2010). Spearmint herbal tea has significant anti-androgen effects in polycystic ovarian syndrome. Phytotherapy Research, 24(2), 186-188.
• Irani, M., & Merhi, Z. (2014). Role of vitamin D in ovarian physiology and its implication in reproduction: a systematic review. Fertility and Sterility, 102(2), 460-468.
• Kristeller, J. L., & Wolever, R. Q. (2011). Mindfulness-based eating awareness training for treating binge eating disorder. Eating Disorders, 19(1), 49-61.
• Richter, E. A., & Hargreaves, M. (2013). Exercise, GLUT4, and skeletal muscle glucose uptake. Physiological Reviews, 93(3), 993-1017.
• Schwartz, R. C. (2021). No Bad Parts: Healing Trauma and Restoring Wholeness with the Internal Family Systems Model. Sounds True.
• Unfer, V., et al. (2012). Effects of myo-inositol in women with PCOS: a systematic review of randomized controlled trials. Gynecological Endocrinology, 28(7), 509-515.
• van der Kolk, B. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Viking.
• Wei, W., et al. (2012). A clinical study on the short-term effect of berberine in comparison to metformin on the metabolic characteristics of women with polycystic ovary syndrome. European Journal of Endocrinology, 166(1), 99-105.
• Yin, J., Xing, H., & Ye, J. (2008). Efficacy of berberine in patients with type 2 diabetes mellitus. Metabolism, 57(5), 712-717.