Program 9



  1. What is Bulimia Nervosa?
  2. How Bulimia Nervosa Affects People’s Lives
  3. What Causes Bulimia Nervosa?
  4. Treatment of Bulimia Nervosa
  5. Starting Points
  6. Monitoring Your Eating
  7. Establishing a Meal Plan
  8. Taking Measures to Prevent Binge-Eating
  9. Learning to Not Diet
  10. Conclusion

  1. What is Bulimia Nervosa?

Bingeing is when large quantities of food are eaten over a short period of time. During a binge-eating episode, the amount eaten is much in excess of the norm and is accompanied by a sense of loss of control. Binges nearly always occur in private while others are kept deceived by an appearance of a ‘normal’ eating pattern.

Bulimics and binge-eaters often binge in the kitchen or while shopping and the food is consumed very quickly usually with a lot of drink. The extreme craving for food during a binge can make people feel desperate to meet their need, resorting to stealing from shops, eating other people’s food or eating food that has been thrown away.

A person may consume between 1500 and 3500 calories during a binge. The food eaten in a binge tends to be bulk foods which are filling, have high calories content and are usually omitted from their diet due to being seen as fattening. The amount of carbohydrates consumed in a binge is nearly the same as in a normal meal. Binge-eating may be triggered by having tempting foods available, thinking about food, concern about shape and weight, not fitting into clothes, feeling depressed, anxious or angry.  

After a binge the initial sense of relief is quickly replaced by negative feelings such as depression, disgust, guilt and shame.

See Program 1: Coping Strategies Counselling Advice – Shame, Guilt and Program 12: Overcoming Depression.

Tiredness, stomach ache, dizziness and headaches may ensue and there is a feeling of being extremely full and bloated.

Bulimics use extreme methods to compensate for overeating due to fearing weight gain. These include dieting, self-induced vomiting, misusing laxatives, diuretics and ‘diet pills’.

Binge-Eating Disorder is not associated with compensatory behaviour for overeating.

Where there is continuous overeating but no bingeing, then the sufferer has Compulsive Over-Eating Disorder.

Bulimics may be underweight, normal weight or overweight. Most people with Binge-Eating Disorder are either overweight or obese. Although their weight may be ‘normal’, bulimics tend to be strongly discontented with their body shape – they overestimate their actual size and their ‘ideal’ size is unrealistically small. Their low self-esteem is strongly associated with this distorted body image.

See Program 1: Coping Strategies Counselling Advice – Improving Your Self-Image and Combating Self-Harm, Coping with the Need for Approval and Program 16: Overcoming Low Self-Esteem.  

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          2. How Bulimia Nervosa Affects People’s Lives

Symptoms of depression, anxiety and anger are common in bulimics and are directly related to their eating disturbance.

See Program 1: Coping Strategies Counselling Advice – Forgiveness, Program 6: Overcoming Anger, Program 8: Overcoming Anxiety and Program 12: Overcoming Depression.

Depression may be due to guilt and shame about binge-eating and vomiting; feeling worthless due to lack of control over their eating and inability to attain their desired shape and weight.

Anxiety is caused by concerns about food, eating, shape and weight; worrying in situations where they feel particularly fat or where food is available.

Anger may result in taking laxatives; hitting themselves as self-punishment; cutting themselves as self-punishment and to release tension, prior to or after a binge.

Binge-eating tends to be done in secrecy and has the effect of isolating the bulimic. Sufferers may withdraw completely from mixing socially when they binge or feel they have gained weight. Partners and children may have to deal with the bulimic’s mood swings, caused by trying to control their eating. Family meals may be a difficulty. Financially binge-eating is expensive and may lead to debt – stealing from shops can result in prosecution in the courts.

When bulimics recover they find that their interpersonal relationships improve – they socialize freely and have a much happier family life.

See Program 1: Coping Strategies Counselling Advice – Social Skills Training, Communication Training, Negotiation Training, Troublesome Emotions and Program 13: Overcoming Destructive Relationships.

Physical effects of binge-eating and compensating for overeating include:

A sense of being full and bloated after a binge, breathlessness, abdominal pain and general digestive problems such as constipation and diarrhoea.

Dieting can result in weight gain over time, menstrual periods may become irregular or stop altogether and in severe cases infertility occurs.

Repeated self-induced vomiting:

Erodes teeth.

The salivary glands swell causing a puffy face which may be interpreted as weight gain, leading to further vomiting.

The throat may be damaged and become infected.

Violent vomiting may cause the oesophagus (the tube joining the mouth to the stomach) to rupture – this is a medical emergency.

The oesophageal sphincter muscles at the top of the stomach can become weak so cannot prevent the contents of the stomach returning into the mouth, which can be distressing.

The process of vomiting, drinking and vomiting again causes electrolyte disturbance (an abnormality in the balance of body fluids and salts).

People can become dependent on laxatives and diuretics and need increasingly larger doses. Stopping taking laxatives can lead to constipation and water retention – the latter also occurs with stopping taking diuretics. Laxative and diuretic misuse can cause electrolyte abnormalities. Large doses may damage the gut wall. Diet pills may result in agitation or depression. When bulimics return to normal eating habits their bodily health is soon restored.

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          3. What Causes Bulimia Nervosa?

Some people are vulnerable to Bulimia Nervosa. There are also factors which trigger the disorder and maintaining factors keep the disorder going by preventing spontaneous recovery. A combination of physical, psychological and social factors lead to the onset of eating disorders.

Vulnerability Factors:

Physical Factors:

Eating disorders may be genetically inherited but then again a similar family environment may be another explanation for the tendency of eating disorders to run in families. It has been suggested that eating disorders may ensue from an inherited tendency to depression but this is not clear. A person’s weight is to an extent inherited and bulimics tend to be overweight which makes them vulnerable to eating problems.

Psychological Factors:

Many anorexics develop bulimia nervosa – this may be due to their state of starvation or their dieting and preoccupation with food. Low self-esteem, perfectionism and alcohol abuse is associated with eating disorders.

See Program 1: Coping Strategies Counselling Advice – Competitiveness and Perfectionism, Frustration, Procrastination, Persistence and Program 4: Overcoming Addiction.

Social Factors:

Women seem to suffer nearly exclusively from binge-eating and bulimia nervosa. The media portrays an increasingly thinner image, to be fashionable in recent decades, causing more women to diet and develop eating disorders. Mothers can pass on their dieting habits to their daughters. Family relationships are more disturbed for those with eating disorders although it is unclear whether these problems precede or are caused by the eating disorder.

Triggering Factors:

Physical Factors:

Favourable remarks about weight loss after an episode of illness may result in a desire to maintain that weight by dieting.

Psychological Factors:

Dieting sets off binge-eating and bulimia in the great majority of people. Paradoxically for binge-eaters, small lapses in eating when dieting, leads to an abandonment of all efforts at dieting and consequent overeating. Depressed mood and alcohol consumption are also factors which produce this paradoxical behaviour or counter-regulation effect in dieters. Some people overeat in response to stress, anger or misery.

See Program 1: Coping Strategies Counselling Advice – Problem-Solving, Program 15: Overcoming Grief AndBereavement, Program 22: Overcoming Stress and Program 23: Overcoming Stress At Work.

Social Factors:

In some people social situations have set off binge-eating (e.g. rejection by a boyfriend).

Maintaining Factors:

Physical Factors:

A particularly low weight serves to maintain eating disorders. A preoccupation with food, depression and a physiological pressure to eat is related to low weight. Low self-esteem and social withdrawal result leading to social isolation.

Psychological Factors:

Low self-esteem and concern about shape and weight lead to dieting and compensating for overeating (e.g. self-induced vomiting). A vicious cycle results because vomiting, laxative and diuretic misuse can cause more overeating since the bulimic feels they do not need to resist the desire to eat due to these compensatory methods. As with binge-eating and dieting, compensating for overeating leads to a preoccupation with shape and weight. All these factors – compensatory methods, binge-eating, and concern about shape and weight, lead to a sense of loss of control and lower self-esteem, although bulimics use this destructive eating pattern to feel in control of their lives.  

Social Factors:

Western society portrays an ultra-thin image of women thus, encouraging preoccupation with shape and weight and reinforcing the bulimic’s beliefs and values.

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          4. Treatment of Bulimia Nervosa

The anti-depressant drugs used to treat bulimia nervosa are:

Monoamine oxidase inhibitors (e.g. phenelzine).

Tricyclic anti-depressants (e.g. imipramine, desipramine, clomipramine and amytriptyline).

Selective serotonin re-uptake inhibitors (e.g. fluoxetine, citalopram, paroxetine, sertraline and fluvoxamine).

With drug treatment the frequency of binge-eating, vomiting and laxative misuse decreases by about 50-60%. There is also a decrease in preoccupation with food and eating, and an improvement in mood. Limitations are that binge-eating does not cease altogether, dieting of patients remains unaffected and after the initial benefit there is a tendency to relapse whether continuing taking the medication or not. Many bulimics are reluctant to accept drug treatment.

Of the psychological treatments, cognitive behaviour therapy reduces binge-eating, vomiting and laxative misuse by about 90% and as much as two-thirds stop binge-eating entirely. Dieting is reduced, mood improves and patients are less preoccupied with shape and weight. There is evidence that the positive results of cognitive behaviour therapy are maintained.

A combination of anti-depressant drug and psychological therapy may be considered although not always necessary due to the established benefits of cognitive behaviour therapy.

There are four levels of treatment of increasing intensity:

Supervised self-help.

Anti-depressant medication and supervised self-help.

Individual cognitive behaviour therapy.

Interpersonal psychotherapy, day patient or inpatient care.

Some people recover on their own – others need varied levels of help.

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                  5. Starting Points

In diagnosing eating disorders, anorexia nervosa takes precedence in diagnosis and treatment over bulimia and bulimia over binge-eating that is not associated with compensatory behaviours. Those suffering from anorexia as well as bulimia may find this advice detrimental and should:

See Program 7: Overcoming Anorexia Nervosa.

If you have a medical condition which is affected by eating (e.g. diabetes) or you are a pregnant woman, you need to seek medical care.

It is in everyone’s interests that you make resuming normal eating habits your first priority. You may feel that you need additional help and wish to seek a course of psychotherapy or counselling. Expect to have setbacks with the given advice. Progress may be slow but keep going.

Find a healthy weight according to your height and remember that weight fluctuates by 2-3 pounds in either direction. You may never attain your ideal weight due to it being unrealistically low, but is weighing a few pounds less, worth the cost of disturbed eating habits?

Try to restrict yourself to weighing at a set time once a week. Endeavour not to be preoccupied with shape and weight and avoid frequent checks on your weight (e.g. regularly inspecting yourself in a mirror).

Perceived or actual overeating can lead to purging – vomiting, laxative and diuretic misuses are entirely ineffective methods of losing weight. Excessive exercise to compensate for overeating is unhealthy and discouraged. Diet pills merely have a temporary effect and can be addictive. They should not be taken without medical supervision.

Deal with any negative thinking. When you have all-or-nothing (black-and-white) thoughts (e.g. ‘I’m a complete failure’) – note your negative thought, consider the evidence for and against it and find alternative more positive thoughts.

See Program 1: Coping Strategies Counselling Advice – Modifying Maladaptive Thinking.

Also – See Program 1: Coping Strategies Counselling Advice – Criticism and Countering Self-Criticism.

You may lack self-confidence.

See Program 1: Coping Strategies Counselling Advice – Assertiveness Training, Neuro-Linguistic Programming (NLP), Building Confidence I, Building Confidence II, Building Confidence III and Building Confidence IV.

Look after your health.

See Program 1: Coping Strategies Counselling Advice – Nutrition, Exercise, Managing Your Time and Sleep Management.

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6. Monitoring Your Eating

You need to record your eating in detail so that you can understand what is occurring with your eating in order to be able to make changes.

Make a table with six columns for each day:

In column one: Record the time food is eaten.

In column two: Record with reasonable precision all food and liquid consumed during the day, even when you are binge-eating – try to do this immediately after eating. Do not record the calories content and put in brackets any episodes of controlled eating which would constitute a ‘normal meal’.

In column three: Record precisely where the eating took place.

In column four: Mark in this column with an asterisk any food noted which you felt was too much to have eaten either due to the quantity or type of food (e.g. chocolate).

In column five: Record any episodes of vomiting, laxative/diuretic misuse or excessive exercise.

In column six: Record the circumstances in which eating occurred, your thoughts and feelings especially after episodes of binge-eating. Note the occasions you weigh yourself and check your shape.

Review your monitoring sheets each week to try and recognize any patterns in your eating:

Are there particular times or situations that trigger binges?

Compare the types of food you eat during binges and at other times.

Are there times when you go for long periods without food and does this cause you to binge?

Are there times when you find you are more in control of your eating?

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7. Establishing a Meal Plan

You need to eat three meals and two or three snacks a day. The intention of regular meals is to replace your binges so you will be eating much less overall and will not become fat as you might fear at first. It is important that you eat only at the planned times and stick to this plan since you cannot at this stage trust your feelings of hunger.

Write down a plan of times when you will eat even if you are not hungry and ensure you do not eat at any other times. This way the pattern of not eating at all then overeating is replaced with a pattern of regular eating.

In your plan have times for: breakfast, snack, lunch, snack, dinner, snack. At these times you must eat and you will have the reassurance that you will not have to wait long to eat again. There should not be more than 3-4 hours between planned meals. You are likely to need a special plan for weekends and holidays.

You may want to start with low-calorie food which does not lead to a binge, vomiting or taking laxatives, but it is important that you get enough to eat – otherwise, you will be starving and will lose control and binge. To decide how much to eat at the planned meals you could see if you feel like a binge soon after these planned meals and if so then increase the amount to be eaten at set times accordingly. Alternatively, you could get meals for one from the supermarket or use someone who eats ‘normally’ as a reference point.

Plan the contents of meals and snacks in advance – you may wish to do this just before a meal or a day in advance. Make sure you decide before you start a meal exactly how much you are going to eat and adhere to this set amount since any feelings of hunger cannot be relied upon. If you are not getting enough to eat in your meals do not alter your plan until you review it for the next day. Try to examine your monitoring sheet at the end of each day to make appropriate alterations.

If you find it difficult to establish an entire meal plan you could start by instituting the easiest meal then when this has been achieved, focusing on the next easiest meal of the day and so on until you have set up a complete meal plan. You will find it difficult but the aim is to gradually reduce binge-eating and for regular eating to eventually become the norm.

If you do binge, you must not give up your meal plan for the rest of the day – resolve to eat the planned meals since this is the only way to prevent further loss of control.

You may have disruptions and need to revise your plan – try to keep it as close to the original as possible. If you have a special meal, do not compensate by missing a planned meal that day or eating less the next day as this will only lead to a binge.

If you do not binge you will not feel the need to vomit. Vomiting encourages overeating so if you feel the urge to vomit, even when sticking to your meal plan, resist it. Try distracting yourself and being with people to fight the urge to vomit – at first you will find it hard but eventually you will overcome the urge altogether.

See Program 1: Coping Strategies Counselling Advice – Distraction Techniques.  

Some people vomit after eating anything at all. Try dividing the day into six parts and eating the planned meal for the part of the day that is easiest without vomiting during this time. Next, try to increase this to another part of the day and so on until you have stopped vomiting entirely.

Try not to be distressed if you feel you are more preoccupied with food when planning your meals than before when your eating was disorganized. You may become increasingly preoccupied with shape and weight but regular checks will confirm that the meal plan is not resulting in weight gain and fatness.

Think of the day as divided into six sections and each successfully completed section is an achievement. In this way if anything goes wrong in one section, the day will not be ruined, since you can endeavour to not slip-up in the rest of the sections.

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8. Taking Measures to Prevent Binge-Eating

You need to find strategies to help you stick to your meal plan and resist the urge to binge. Although you may have outside help, it can be invaluable to ask a friend or relative to also support you. Someone you respect and trust is highly likely to understand your problem and not be critical. They can have meals with you or you can spend time with them or phone them when you feel the urge to binge.

Eat only in one or two specified places and try not to eat at all in places you binge. When you eat, do so slowly and avoid distraction (e.g. watching television). Before a meal, plan out what you will do when the meal is finished.

Buy food in small quantities and avoid keeping large supplies of food at hand. Shop for food using a list and perhaps with a friend and do not carry more money than you need or credit cards. Avoid shopping when hungry or likely to binge. Ensure you do not have left over food available as you might lose control over your eating. Be firm in refusing food when pressurized by others to eat.

Take the day in stages, so if one stage goes wrong, you can continue with your meal plan so that you are successful in the rest of the stages, so make progress.

By examining your monitoring sheets you will be able to see any patterns in your binge-eating and arrange to make things easier (e.g. by avoiding situations in which you binge). People tend to find it hard to control their eating after taking alcohol so if you cannot drink moderately do not drink at all while you are trying to establish a regular pattern of eating.

It is useful to have a list of distracting activities for when you feel the urge to eat. The more you intervene in this manner the easier it will get to intervene in the future and avoid eating outside your allowed eating times of planned meals. Try to list activities that are easy to do, indulgent, take you away from where you usually eat, involve using your hands and are not tasks or duties. Keep the list at hand and with time you will find the activities that are effective for you.

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9. Learning to Not Diet

Although you may be sticking to your meal plan and have reduced or stopped binge-eating you will still be preoccupied with food and eating and this may increase, if you are only consuming small amounts of low calorie foods. If you are to progress you have to stop dieting and this can only be dealt with when there has been noticeable improvement from a regular meal plan.

Dieting is of three types:


Eating too little.

Avoiding particular types of foods considered to be ‘binge’ foods.

The meal plan eliminates fasting and you need to experiment to find out what constitutes a ‘normal’ amount of food to you as this varies from person to person. It is necessary that you broaden your diet and stop thinking of certain foods as ‘binge’ foods hence, forbidden. The reason you binge is because of lack of control over your eating and from avoiding ‘binge’ foods at other times. It is crucial you realize that there is no need to feel concerned when eating small amounts of your ‘binge’ foods and that this will not make you gain weight.

Make a list of foods you avoid because they are ‘fattening’ or trigger binges. Put the most ‘forbidden’ food at the bottom of the list and make a hierarchy so that the least fattening food is at the top. Divide the hierarchy into three groups – foods which cause minor, moderate and extreme difficulty.

Starting with the least fattening of the ‘minor’ difficulty foods, try to eat that item as part of your planned meals every second or third day. Only do so if you feel no trouble will ensue. Continue down the list to the most ‘fattening’ of the ‘minor’ difficulty foods. When you feel you no longer need to avoid these foods proceed to dealing with the ‘moderate’ difficulty, then the ‘extreme’ difficulty foods in the same manner.

The task is complete when you feel you can eat what you want in moderation and decide how often and in what quantity without fearing ‘fatness’ or loss of control and bingeing. However, you should try to eat healthily and remember that if you were avoiding (e.g. chocolate), including this a few times a week in your meals is far less than you would be eating if you were still bingeing.

You need to be able to cope in all situations – make a list of all situations in which you find difficulty with eating and make an hierarchy starting with the least difficult to the most difficult and work your way down the list using the principles you have learned and practise coping in these situations in a safe environment until you feel you can cope in all circumstances.

See Program 1: Coping Strategies Counselling Advice – Controlled Breathing and Relaxation Techniques, Eye Movement Technique (EMT), Mood Induction Procedure, Rational Emotive Imagery (REI), Imago Graded Exposure and In Vivo Graded Exposure.

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10. Conclusion

Your concern about your shape and weight led to dieting and subsequent loss of control over eating and ensuing problems. As you resume ‘normal’ eating habits and develop your interests you will become less concerned with shape and weight.

Try not to judge yourself in terms of shape and weight as this leads to eating problems. Consider how important shape and weight are in how you value others and how they value you. It is likely that shape and weight rank very low on both lists of valued attributes in each other.

When you attribute negative events or feelings to your shape or weight try to look for other more rational perspectives. Perfectionism can result in guilt and self-criticism which make you feel bad and cause concern about shape and weight, leading to dieting and binge-eating. Try to treat yourself as you would a friend.

Particularly distressful events can lead to a lapse; you may binge but you must realize that there were extenuating circumstances – so do not despair and give up. If you feel there is a chance you may binge, work through the skills you have learned from this advice; your confidence will return and you will be at ease with eating. Be alert for when you feel bad about your shape and weight, and want to diet – avoiding such feelings and preoccupations are your way forward.

See Program 1: Coping Strategies Counseling Advice – Relapse Prevention.

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