This manual contains information and ideas which have been produced by members of The Cullen Centre over the past 10 years. Cullen Centre Tipperlinn House Royal Edinburgh Hospital Morningside Edinburgh EH10 5HF Tel: 0131 537 6806 Fax: 0131 537 6104 SELF-HELP MANUAL FOR BULIMIA NERVOSA by Dr Chris Freeman & Gillian Downey, 2001 A SELF HELP MANUAL FOR BULIMIA NERVOSA WHAT IS BULIMIA NERVOSA? Bulimia nervosa is becoming more frequently seen in our society. Characteristics of the disorder involve the sufferer "bingeing" on large amounts of food, during which she/he experiences feelings of extreme loss of control. Interrupting such a binge can provoke extreme anxiety and agitation. Bingeing leaves the sufferer feeling guilty, disgusted with themselves and afraid of weight gain. The sufferer may compensate for this by vomiting, exercising, fasting, abusing laxatives or often by some combination of these. Most people suffering from Bulimia are continuously "dieting" and their eating patterns are often chaotic. An important feature of the disorder is the sufferer’s perception of themselves as fat. They maintain a very negative view of their body which perpetuates their low self-esteem and causes them to avoid many social situations. Most sufferers describe low mood and a marked reduction in their quality of life although they often appear to be coping well and can disguise their disorder from family and friends. About the Self Help Manual •••• This manual has been developed to accommodate the need for an alternative to treatment within the health service, as for many people there are barriers to referral to NHS facilities. •••• It is designed as a first line intervention for bulimia, and we recognise that some people may require further treatment - this manual is not intended to replace other therapy which is currently available. •••• The manual uses cognitive behaviour techniques. •••• Its remit is to teach alternative, less destructive coping strategies to replace bingeing and vomiting. •••• Underlying conflicts are almost certainly present and cannot be addressed by any self help package. •••• Much of the material in the package is taken from the manual for the 'Bulimia First Aid Group', which is a structured group program which has been run at the Cullen Centre for some years now. •••• It has become apparent, that for a variety of reasons, for some people group therapy is not acceptable. IS THIS MANUAL SUITABLE FOR YOU? WHY SELF-HELP? •••• Many people want to try to help themselves first. •••• Self-help compliments specialist help. •••• Practical considerations such as time and availability of treatment. •••• Self-help can be alone or in groups. •••• You can start when you feel ready. •••• You can control the pace of your change. •••• There is no treatment which is "best". HOW TO USE THIS MANUAL 1. First and foremost your MOTIVATION is essential if this manual is to have any beneficial effects. Start working on it when you feel ready, but remember there may well never be a perfect time to start to tackle your eating disorder. 2. Each module should be worked through thoroughly and carefully before you move on to the next, as each module tends to build on the previous one. We would suggest that it takes roughly one week to carry out the 'homework' tasks that are set for each module, and that you attempt one module only per week. 3. You should consider working through the manual as a time in which to attain self-knowledge and a personal experiment for facilitating recovery. This involves risk-taking and testing out the suggestions made. Progress depends on attempting ALL the homework assignments. 4. Change involves a persistent effort in examining beliefs about weight, shape, food and the underlying issues which may perpetuate an eating disorder. 5. It is important that you take credit for your own progress and confront your beliefs and fears at a pace that is comfortable for you. Summary: •••• Motivation •••• Working through section by section •••• Knowledge, experimentation and risk taking Completing homework tasks •••• Examining your beliefs •••• Progress at your own pace •••• Taking credit for your progress MODULES Module 1: A What is bulimia? B Breaking the Cycle C Principles of Normal Eating Module 2: A Physical and Emotional Side Effects of Bulimia B Dietary Advice Module 3: A Changing the Way you Think B Steps of Cognitive Therapy Module 4: Thinking Errors Module 5: Looking for Rational Answers Module 6: A Coping with Anxiety; Relaxation Training B Coping with Anxiety; Other Methods of Coping Module 7: Body Disparagement Module 8: Assertiveness Module 9: How to Help Yourself in the Future Appendices: a) Booklist b) Self-help Organisations c) Sample Food and Thought Diaries d) Script for Progressive Muscular Relaxation Exercises e) Body Mass Index (BMI) Chart MODULE 1 A WHAT IS BULIMIA? 5 CASE EXAMPLES Deborah, a 25 year old architect had recently been discharged from hospital where she had been treated for anorexia nervosa. Her weight was now within the normal range for her age and height. However, she still found her thoughts to be preoccupied with food, eating and weight. She started starving herself all day while at work, then by evening, when she was at home alone, she would have such strong cravings for food that she would binge, sometimes for 2-3 hours, vomiting when she felt her stomach tense and uncomfortable. She had told none of her family or friends about her problems because she felt so ashamed. George had always been teased at school for being "fat". At the age of 15 years, he had started himself on a strict diet in order to lose some weight and make himself feel better. He initially lost weight, but his parents continually expressed anxiety over his restricted intake, so he started eating apparently "normally" again with his parents but would secretly go off to the toilet as soon after a meal as possible and make himself sick. As time went on, he began bingeing and vomiting whenever he had the house to himself. Often up to 6 times per day. His parents, unaware of what was going on, were relieved to see him eating "proper" meals but were worried by his apparent change in personality from a happy-go-lucky child into a moody, irritable and secretive adolescent who seemed to have no friends and never went out if he could help it. Jill was a 37 year old housewife and mother of three. She spent most of her day running after the children, looking after her frail mother and keeping the house in order. Her husband often worked away from home and she didn't have many friends in the area, so she didn't tend to go out much. She felt very alone and unhappy. She didn't sit down with her family at meal times just picking at food as she went from task to task. However, when the children had gone to bed and she was alone in front of the television, she often used to consume several packets of chocolate biscuits as she felt food comforted her. Guilt over her actions made her vomit afterwards. She was now 3 stone overweight but felt too miserable to do anything about it. Paul was a 21 year old student of law when he developed bulimia. On returning home from lectures he would stop off at the supermarket and buy bread, biscuits and confectionery, often consuming most of it before he got back to his flat. He had tried inducing vomiting but had found himself unable to do so. Instead, he took 20-30 laxative tablets after each binge and did frequent exercise to burn off the rest. He felt permanently exhausted and found it hard to concentrate on his lectures, often falling asleep during them. His preoccupations with food made studying hard and eventually he dropped out of university after failing his second year exams. MODULE 1 A WHAT IS BULIMIA? 6 Ann was a 20 year old unemployed secretary. She had developed bulimia 10 months previously following a split with her fiancé and had been unable to work since due to a combination of depression and her chaotic eating pattern. She was now in severe financial debt as a result of buying food, clothes and beauty products on credit, in order to make herself "feel better". She would never try on clothes in the shops as she couldn't bear exposing her body to others in the changing rooms nor seeing herself in the numerous mirrors. Unfortunately, she couldn't face the shop assistants to take back the ones she didn't like, so they hung in her wardrobe untouched. She felt comforted when she bought things, although she knew she couldn't afford to pay for them when the bills came through. Do you recognise yourself in any of these descriptions? Perhaps no particular case fits you exactly but there may be parts from Deborah, George, Jill, Paul or Ann's stories that are familiar to you. MODULE 1 A WHAT IS BULIMIA? 7 BULIMIA MEANS DIFFERENT THINGS TO DIFFERENT PEOPLE The symptoms can vary in type and severity. Below is the currently accepted definition used by Psychiatrists and Psychologists:- Criteria for Bulimia Nervosa: a. You must have recurrent episodes of binge-eating. This means rapid consumption of a large amount of food in a discrete period of time, usually less than two hours b. During the eating binges you should feel a loss of control over your behaviour c. You should regularly engage in either self-induced vomiting, use of laxatives, strict dieting, fasting or rigorous exercising in order to counteract the effects of your binge eating d. You should have a minimum average of two binge-eating episodes per week for at least three months e. You should have marked anxious over-concern with body shape and weight This is what the 'experts' say you are supposed to do in order to have Bulimia Nervosa. Remember these are not all the features of Bulimia Nervosa, you may have other symptoms but not all the above. Some people binge only occasionally and their eating disorder does not significantly interfere with their lives. For others, the problem can be more consuming. They may binge and vomit/purge several times a day, be unable to hold down a job, be severely physically run down, feel emotionally out of control and socially isolated. Obviously there is a continuum between a "normal" eating pattern and that of someone with a severe form of bulimia nervosa. See appendix e) for more information on Body Mass Index. overweight underweight "norm al eating" occasional bingeing bulim ia nervosa mild m oderate severe 30 25 20 15 BM I = Body M ass Index It is a way of relating your weight to your height. It is a m uch better guide than weight tables. B M I MODULE 1 A WHAT IS BULIMIA? 8 Homework assignment 1a • What does bulimia mean to YOU? - Is it consuming all your thinking time? - Does your day revolve around food? - Are you too ashamed to talk to others about it? - Do you need it to cope with the stresses of daily life? - Has it led to you becoming socially isolated? - Has it affected your physical health? • In the space below, jot down a few thoughts on how bulimia affects your life: • What are the advantages and disadvantages of Bulimia? Disadvantages of your eating disorder may spring to mind very easily e.g. tiredness social isolation dental decay low mood/irritability financial strains Advantages may be less obvious to you and in some cases they may no longer actually be present. However, they have almost certainly been there at sometime. Take some time to think about them. The examples below may help you get started: e.g. as a means of coping with day-to-day stresses as a comfort when you feel alone or misunderstood to blank out family expectations of perfection In the space below, under each heading try to list down at least five advantages/ disadvantages for you of having bulimia. ADVANTAGES DISADVANTAGES 1 1 2 2 3 3 4 4 5 5 MODULE 1 B BREAKING THE CYCLE 9 THE VICIOUS CYCLE Below is a diagram showing the VICIOUS CYCLE which, although you may not have realised it, is almost certainly controlling the way that you eat. How you got into this cycle is less important than what makes you stay there. Stressful situation Worrying about shape and weight Diet/purge Binge Binge Diet/purge Self-reproach/ disgust VICIOUS CYCLE MODULE 1 B BREAKING THE CYCLE 10 WHAT INDUCES YOU TO BINGE? The diagram below suggests certain psychological triggers for bingeing but also shows the less obvious but nevertheless strong physiological factors which occur when someone is in a starvation state. You may say that the physiological drives can't apply to you because you are not underweight. This is in fact wrong as strict dieting, even at normal/above normal weights induces: 1. Preoccupation with food 2. Carbohydrate cravings 3. Strong drive to binge Carbohydrate cravings Loneliness Feelings of worthlessness Relationship problems Stress at work Preoccupation with food BINGE MODULE 1 B BREAKING THE CYCLE 11 WHAT THEN TRIGGERS DIETING/PURGING? Physical discomfort of full stomach Striving to gain control Fear of becoming fat Ashamed of bingeing DIET/PURGE It can thus be seen how the strong drive to diet/purge after bingeing inevitably results in a starvation state which increases the chances of further bingeing and so the vicious cycle continues. The figure below shows how a typical bulimic's calorie load can vary over a day in comparison to that of someone with a more regular eating pattern. + _ Calorie load B B B V/P V/P V/P S S b s l s d s Time 0 KEY: B binge V/P vomit/purge S starvation b breakfast l lunch d dinner s snack Bulimia Nervosa Normal Eating Pattern The irregular pattern of eating and wide differences in calorie load of a bulimic results in a continual vulnerability to strong biological urges to binge. Eating more regularly and frequently, in time, reduces the urge to binge allowing the body to revert to its normal "set point" weight which is maintained despite fluctuations in the calorie intake of the diet. MODULE 1 B BREAKING THE CYCLE 12 OTHER METHODS OF WEIGHT CONTROL THAT PERPETUATE THE CYCLE OF BULIMIA Method of Weight Control Effectiveness in Controlling Weight Perceived Benefits/Losses Possible Adverse Effects on Body Self-induced vomiting Absorb at least 25% of binge calorie load "Permits" bingeing but reduces motivation to change - Sore bleeding throat - Swollen glands (makes face look fat) - Disturbs body salt levels - Reduces tolerance of stomach to food Laxative Abuse Lose water not calories Creates feeling of "emptiness" but without ridding body of food - Dehydration - "Lazy" bowel - On attempting to stop causes bloating/ water retention/ constipation Diuretics Lose water not calories Creates feeling of "emptiness" but without ridding body of food - Dehydration - Kidney damage (if used long term) It is important to remember that: • Recovery from bulimia nervosa involves you TAKING CONTROL of your eating rather than letting it take control of you. •••• Recovery involves RISK TAKING and CHALLENGING your previous patterns of eating. •••• CHANGES may seem daunting, even terrifying but try to remember how miserable you were feeling when you initially asked for help. The PRINCIPLES OF NORMAL EATING, shown overleaf, are STEPS towards normal controlled eating that should be tested out SLOWLY and at a pace that is tolerable to you. Remember, you are more likely to take fright and give up if you try to be too ambitious too soon. Once these guidelines have been put into practice for some time, you will then be in a much stronger position to make realistic reductions in your intake if you still want to lose weight. MODULE 1 C PRINCIPLES OF NORMAL EATING 13 1. Use diaries or exercise books to record your eating. You may wish to do this in the form of diaries we provide (see appendix c). Write down everything you eat and drink with details of times and how you were feeling while you were eating. 2. Try to eat in company, not alone. 3. Do not do anything else while you eat (except socialising), even if you are bingeing. For instance, do not watch TV, do not read. It is usually okay to listen to music but try to concentrate on enjoying your meal. 4. Plan to eat three meals a day plus two snacks. Try to have these meals and snacks at pre- determined times. Plan your meals in detail so that you know exactly what and when you will be eating. In general, you should try to keep one step ahead of the problem. 5. Plan your days ahead; avoid both long periods of unstructured time and over-booking. 6. Only have planned food in the house, don't stock up too far ahead. If you feel you are at risk of buying too much food, carry as little money as possible. 7. Identify the times at which you are most likely to over eat, using your recent experience and the evidence provided by your diary. Then plan alternative activities making sure they are not compatible with eating such as meeting a friend, exercising or taking a bath. 8. Whenever possible, avoid areas where food is kept. Try to keep out of the kitchen between meals and plan what you will do at the end of each meal. If necessary, get out of the house completely - the washing-up can wait. 9. Don't weigh yourself more than once a week. If possible, stop weighing yourself altogether. Don't try to lose weight while you are trying to learn new eating habits. Once you are eating normally you may reduce weight by cutting down the quantity you eat at each meal rather than skipping meals. Remember, gradual changes in weight are best. 10. If you are thinking too much about your shape and weight, it may be because you are anxious or depressed. You tend to feel fat when things are not going well. Can you identify any current problems and do something positive to try and solve or at least minimise them? 11. Use exercise. Regular exercise increases metabolic rate and helps suppress appetite, particularly carbohydrate craving. MODULE 1 C PRINCIPLES OF NORMAL EATING 14 12. Take particular care in the days leading up to your period. For many women food cravings increase at this time. 13. Avoid alcohol. It can increase cravings and reduce your control. 14. Set aside some time daily to reflect on how you are coping. If some of your strategies are not working, try others. 15. Set yourself limited realistic goals, work from hour to hour rather than from day to day. One failure does not justify a succession of failures. 16. Note your successes, however modest, in your diaries. Every time your eat normally you are reinforcing your new good eating habits. We do strongly recommend that you establish a regular eating pattern based on the principles of normal eating. This should include:- BREAKFAST SNACK LUNCH SNACK DINNER SNACK The above recommendation is one to aim for and is unlikely to be achieved quickly and without taking risks and experimenting. Summary •••• Bulimia Nervosa is an eating disorder whose symptoms vary in nature and severity - you don't have to have them all to be ill. •••• Binge-eating, feelings of loss of control, attempts to restrict intake/rid the body of food and an altered body image are core features of this condition. •••• There will be advantages and disadvantages to you in being bulimic. •••• Eating regular meals will help you break the vicious cycle of binge - purge/diet. •••• In order to take CONTROL you have to be MOTIVATED and willing to take RISKS. MODULE 1 C PRINCIPLES OF NORMAL EATING 15 Homework Assignment 1b •••• Over the next week try to incorporate two steps from the 'principles of normal eating', one of which should be number 1., i.e. start to keep a diary of your eating. •••• You will notice that the food diaries provided with this manual (appendix c) have a section for you to record what you eat, when you binge, when you vomit and when you use laxatives or diuretics - fill this in honestly and completely. •••• We will describe the thought diary in module 3. For the moment it may be helpful for you to begin to record general thoughts and feelings that you have had during the day - write something down each day in terms of how your mood has been, what stresses you have been under, relationship difficulties etc. •••• It’s also helpful for you to record something positive – jot something down each day. •••• Take these diaries seriously. They can become a valuable resource in your attempt to 'give-up' bulimia. Write down which 'principles of normal eating' you are going to attempt this week (one of them should be number 1 from the list, choose one other then write them down below - use diaries):- e.g.1. Use diaries to record my eating. 2. etc............. Note: •••• You should try to complete each exercise in this module before moving on to the next one. If you have been unable to do this so far, go back and try again. Remember RISK TAKING is required to gain control over your bulimia. •••• If you have managed to complete the tasks, recognise your success by giving yourself a treat e.g.. go to the cinema or relax in a hot bath, etc.... •••• When you feel ready to move on, turn over the page and begin module 2.