OVERCOMING ANOREXIA NERVOSA

1. What Is Anorexia Nervosa?
   • Anorexia Nervosa (AN hereafter) is an eating disorder common in women and physical features are an abnormally low body weight and amenorrah (the cessation of menstrual periods) in girls.
   • Principally AN is a psychological disorder with a fear of fatness or even being the normal body weight. Individuals have a distorted body image and see themselves as fat even when others think them to be extremely under weight.
   • Sufferers may use starvation, exercise, vomiting or purging to maintain a low body weight.
   • As well as being prevalent in women, anorexia occurs in children, men and the elderly.
   • AN occurs in women and men of all ages and across all social classes.
   • Pressure from the media to be thin is not the sole cause of AN which has multiple causes.
   • Most problems in families are the result of AN rather than the cause of it.
   • The majority of women have dieted but only a minority get AN as a result of simple dieting.
   • AN is a serious disorder and often very difficult to treat.
   • Recovery from AN is possible even after many years of continuous severe symptoms.

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2. How Does AN Affect People?
   • PHYSICAL EFFECTS:
     • As you continue to under-nourish your body your metabolic rate slows down and you will lose weight more slowly.
     • Sufferers of AN become deficient in important minerals such as calcium, magnesium, potassium and sodium, resulting in symptoms which include weak muscles, back pain, development of osteoporosis, fatigue, heart problems, severe dehydration and dangerously low blood pressure.
     • Dry skin with an orange tinge and fine hair all over the body may occur due to starvation.
     • When you severely reduce your food intake your body metabolizes its fat reserves then muscle – this can result in muscle wasting and muscle weakness (myopathy).
     • Lack of muscle support to the spinal column results in low back pain and is common in AN.
     • The brain may shrink if starvation is severe and brain functioning may be maintained by utilizing amino-acids usually required for essential body proteins, so causing other tissues to be increasingly weakened.
     • The heart becomes weaker and its efficacy becomes reduced – blood pressure becomes lower and cardiomyopathy can develop where the heart muscle fails to function efficiently.
     • Low blood pressure due to starvation can affect the efficient functioning of the kidneys.
     • Continuous starvation can lead to the shrinking of the gastro-intestinal system causing poor absorption, constipation and abdominal pain.
     • The immune system and the healing of wounds is very much impaired and fungal infections can be common.
     • Sufferers are more sensitive to cold temperatures and hypothermia is common with AN.
     • The uterus and ovaries shrink and amenorrah (cessation of menstruation) occurs. In the unlikely event of pregnancy, there is an increased risk of miscarriage. When the fetus survives the baby is liable to impairment in later life.
     • Some AN sufferers develop a high activity level in response to starvation while others lack energy.
     • Repeated vomiting can result in dental damage, a constant sore throat, heartburn, stomach ulcers and potassium deficiency.
     • Laxative abuse can lead to severe dehydration, water retention, bloating and chronic constipation.
     • Nearly all the physical changes due to AN are reversible by maintaining a normal weight but is a slow process.
   • BEHAVIOURAL EFFECTS:
     • People with AN have daily routines dominated by physical activity and excessive exercise.
     • Other weight-loss behaviours include purging, by vomiting or using laxatives or diuretics after eating, to remove from the body the food consumed.
   • PSYCHOLOGICAL EFFECTS:
     • AN sufferers become extremely preoccupied with food. As well as worrying about the food consumed or to be consumed they may develop a love for cooking for others while they themselves eat separately. Always having to watch what they eat when food is very much a part of social occasions can lead to hostility towards others and increased isolation and loneliness which causes the disease to develop further.
     • Thinking becomes rigid and inflexible with starvation and sufferers tend to have only ‘black-and-white’ thinking.
     • Individuals with AN tend to revert to immature thinking.
     • AN can result in increased obsessions about not only food but other areas such as compulsive neatness and cleanliness. Sometimes these obsessions are imposed on others making the anorexic intolerant of people who do not comply with the obsession and increases their isolation.
     • As AN progresses it reduces the ability to think and sufferers tend to do and say things repetitively.
     • Anorexia may be associated with other disorders such as bulimia, depression, obsessional disorders and anxiety.

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3. What Causes Anorexia Nervosa?
   • VULNERABILITY FACTORS:
     • There may have been feeding problems in childhood perhaps due to a mother with an eating disorder or from comparing with cultural ideals.
     • Research has shown a strong genetic predisposition in the occurrence of AN.
     • Biologically starvation affects the levels of chemicals in the brain, in particular serotonin which is released when we start to eat. Low levels of serotonin, stimulates hunger.
     • Features of family life linked to the formation of anorexia include:
       1. families that avoid conflict;
       2. one parent tends to be over-involved while the other is passive with the child;
       3. too strong family rules and identity such that individuality is hard to express;
       4. sexual, physical or emotional abuse;
       5. highly successful parents who expect similarly of their children;
       6. extreme sibling rivalry.
     • Adolescence is the time when a person develops a sense of identity. If at this time parents prevent the teenager from having control over life, the adolescence may feel that their weight is the only thing they have control over and losing weight may be used to reject the family and to gain a sense of empowerment.
     • There is immense social pressure to be slim – in films and in the media women are portrayed as an ultra slender ideal. Many women feel that being slim will solve all their other problems.
     • From adolescence we begin the search for autonomy – if this is denied then controlling eating may be the only way to exercise self-will and express individuality.
     • Low self-esteem can lead to AN where an individual associates gain of self-esteem with weight loss.
     • Sexual abuse victims may develop eating disorders as a means of gaining control over their life, to make themselves less desirable, as self-punishment or to punish those who have failed to protect them.
     • Separation and loss can lead to the development of AN.
   • TRIGGERING FACTORS:
     • Negative remarks about appearance; separation and loss; pressure to be successful; family and sexual conflicts; feeling over-weight and dieting.
   • MAINTAINING FACTORS:
     1. Fear of fatness;
     2. Rewards of weight loss;
     3. Sense of self-control and approval from others before extreme loss is apparent;
     4. Concern from others;
     5. Avoiding difficult changes of adolescence;
     6. Increasingly distorted body image;
     7. Preoccupation with food and reduced interest in socializing.
   • It is important to remember that no one factor is the cause of the condition.

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4. Treating Anorexia Nervosa
   • The earlier treatment is sought for AN, the quicker the route to recovery. In advanced stages AN can require intensive and long-term treatment.
   • The AN sufferer needs to accept that there is a problem, be willing to receive help from someone and take steps to break free of their extreme dietary restrictions.
   • To seek help you should discuss your problem with your GP. If this is not possible, contact your nearest hospital psychiatry or clinical psychology department, or a local community mental health team.
   • Most people may receive successful treatment as out-patients, getting some form of counselling.
   • Any treatment programme will aim to increase weight to normal range and enable the individual to resume normal eating patterns and avoid resorting to vomiting, laxative abuse and over-exercising to control weight. It will also try to give an understanding of the physical symptoms caused by AN.
   • Hospitalization is resorted to if a person’s condition becomes critical.
   • No drugs will directly relieve the symptoms of anorexia but drugs may be prescribed for associated disorders such as depression and include: minor tranquillizers, anti-psychotics and antidepressants.
   • There are various forms of group therapy for AN and cognitive behavioural therapy (CBT).

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5. Problem Assessment
   • Altering your eating behaviour and body image will be a gradual process. In this program you need to congratulate yourself for successes and not feel too despondent about setbacks.
   • First you need to establish your position now. Write down the answers to and any related thoughts about, what caused you to diet and why the diet was so successful?
   • What stage of AN are you at? :
     • Pre-anorexia nervosa – food causes panic but does not dominate your thoughts and you may have lost some weight but are not severely low in weight;
     • Clinical anorexia nervosa – food dominates your thoughts, you are obsessed with weight gain and have lost considerable weight;
     • AN has become an illness if you have been living on severely reduced food intake for six months. You may feel trapped in anorexic behaviour;
     • When AN is long-standing it may have become a way of life for you.
   • If you are in the last two stages, consider what caused you to proceed through the first two categories.
   • If you have AN you should seek professional help as well as following this program.
   • Be aware of the things that stand in the way of change – these include:
     • lack of commitment;
     • fearing loss of control and change;
     • being isolated;
     • realize that you will have to fight to give up your anorexia.
   • To motivate you for altering your behaviour write down the advantages and disadvantages of anorexia nervosa – do not panic if at this stage the pros outweigh the cons.
   • Look at the statements in your list and do experiments using CBT methods described later. Change each statement to a question e.g. Do I feel in control of myself and my body in this way? Test it out for a few days noting the evidence that arises.
   • Try imagining what it would be like 1-10 years from now for yourself with AN and for a friend who does not have AN. How might your lives be as time progresses – you could imagine meeting and talking about your lives with your friend or do this in real life.
   • To distance yourself from AN write a goodbye letter to your anorexia nervosa about the ways it helped and how you will cope in future.
   • Consider the positive and negative changes that might occur within your family if you recover from AN.
   • Take a positive aspect and set it as an aim and get your family involved e.g. you may feel that without AN, you would enjoy activities with your family. Set this as a target and start by trying to enjoy a family activity.
   • Attempt to get your family to focus on the positive.
   • If you feel you are using anorexia to punish others and feel you cannot approach your family about this, then seeing a family therapist may be helpful.
   • AN is destructive to all relationships and physical relationships may become terminated. Partners need to be made aware of the illness and asked to be supportive when you are ready to alter your behaviour.

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6. Monitoring Your Eating Patterns
   • You need to record, test and control your present eating habits before you attempt to alter anything.
   • Easing your dietary restrictions and giving food less priority is necessary for recovery, which will involve taking risks and challenging your old eating habits.
   • At every stage keep in mind how miserable you were when you first sought help.
   • In a notebook make a diary to record daily everything you eat and drink including any binges and what was consumed in these, the latter written in brackets. Also note the number of portions you eat, how many times you vomit, take laxatives and/or exercise after eating.
   • Targets of normal eating you should aim for in steps are:
     1. Do not eat alone;
     2. Apart from socializing, do not do anything to distract you from concentrating on enjoying your meal, even if you are binging;
     3. Plan a regular eating pattern with breakfast, lunch and dinner plus snacks after each meal.
   • You can make the task ahead easier:
     1. Try to take up an activity that you enjoy and do not involve food or exercise;
     2. Endeavor to recognize triggers that may result in you eating less, and write down reasons for you not to be affected by them;
     3. Avoid letting food and weight dominate your thoughts;
     4. Weigh yourself only once a week - try not to weigh yourself at all;
     5. Anxiety and depression associated with AN will improve with weight gain but if you can, deal with these particular problems;
     6. Try to exercise for enjoyment rather than purely to burn calories;
     7. Do not worry about amenorrah – your periods will return when you reach a healthy weight;
     8. Allocate time to consider whether you need alternative strategies;
     9. Be realistic in your goals and note your successes in your diary.
   • Try to aim for one of the ‘targets of normal eating’ each week by writing it down in your diary.
   • Reconsider your diary at the end of each week and note any changes in your eating patterns. Reward yourself for any successes.

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7. Challenging Negative Thoughts (1)
   • Anorexia nervosa affects your behaviour and your THOUGHTS.
   • Your anorexic behaviour may disappear but if your thinking does not alter, a restricted eating pattern is likely to reappear.
   • Thoughts, behaviour and mood are linked and disturbance in one can lead to a vicious negative circle.
   • Negative automatic thoughts need to be recognized (e.g. ‘I don’t want to live if I get any fatter’) and changed.
   • For a week, in your diary, write down the date, situation, your emotions and negative thoughts.
   • Continue with your food diary and aiming for ‘targets to normal eating’.

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8. Challenging Negative Thoughts (2)
   • Thinking biases include:
     • catastrophizing (predicting the very worst);
     • jumping to negative conclusions (interpreting things without evidence);
     • emotional reasoning (an over-reliance on feelings to guide judgments);
     • ‘I must’ (these thoughts involve feelings of being compelled to do something); disregarding and disbelieving the positives, disregarding and disbelieving others;
     • increasing the strength of the negatives by dwelling on them;
     • all-or-nothing thinking (black-and-white thinking);
     • over generalizing (you notice something that is true and make generalizations about it);
     • mind reading (thinking you know someone’s thoughts when you do not);
     • predicting the future;
     • labeling (calling yourself names);
     • wishful thinking;
     • taking the blame when you are not at fault;
     • being personally affected by things;
     • having unrealistic expectations;
     • over estimating failure and under estimating success.
   • For a week, as you note your negative thoughts in your diary, write down also the type of biased thinking it represents.
   • Continue with your food diary and aiming for ‘targets to normal eating’

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9. Dealing With Restrictive Eating Patterns
   • An individual’s weight will fluctuate daily.
   • With the return to a normal eating pattern your metabolic rate will increase from being slow due to starvation.
   • Food eaten in ‘portions’ can be used to gradually increase your food intake.
   • Carbohydrate foods are eaten in ‘portions’ aiming for 15 ‘portions’ per day. When your eating patterns have improved, this can be adjusted to control your weight change.
   • One portion includes food such as: one slice of bread; one chocolate biscuit; one bowl of cereal; one piece of fruit; one small potato; one bowl of soup; two tablespoons of pasta or rice; one glass of fruit juice.
   • Two portions include food such as: one bag of crisps; one single helping of pudding; one croissant; one fruit yoghurt.
   • Ask your doctor to refer you to someone who can give you detailed information about the ‘Portion System’.
   • Continue with your food diary and aiming for ‘targets to normal eating’.

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10. Dealing With a Distorted Body Image
    • Anorexics tend to have a negative body image – they feel parts of their body to be fat and this makes them believe that they are fat.
    • As a result their self-confidence is seriously undermined.
    • Perfectionism – striving for the unobtainable ‘ideal body’ can lead to a negative body image.
    • General negative feelings such as depression may be replaced by feeling fat.
    • Avoid and confront not looking at or not touching your body, to prevent phobia about your body.
    • Analyze your diaries – how are your feelings and eating linked? What negative thoughts tend to persist? Can you challenge these thoughts and if so, how does your behaviour alter? Consider which coping strategies are most helpful to you so far.
    • Understanding the root of your negative body image will help you to gradually alter it.
    • Write your body’s history: Take specific ages such as 6, 9, 12 and 16. Use old family photos to remember how you felt about yourself and your body at the time, the state of relationships and family circumstances. Begin when you felt comfortable with your body then write about how your negative body image formed. Continue to include your feelings after developing AN and use any photos you may have of this stage.
    • It may help to:
      1. Re-write your story as if you had not formed a negative body image;
      2. Create a positive body image you can keep with you and listen to when you have negative thoughts;
      3. Try not to take notice of the media;
      4. Keep a positive diary for a week noting only positive bodily experiences, to combat the biased thinking of AN.
    • Some helpful activities are:
      1. Imagine how you will be 10-20 years from now. What will your goals be and will you need to make any alterations to achieve them? ;
      2. Consider and compare how you see yourself and how others see you. How would you like to see yourself and be seen by others? What changes are required for this and how would you make them? ;
      3. Think of someone you respect who is not overly thin. What qualities do they have that impress you and can you develop these in yourself? What do you think matters to them? ;
      4. Consider your reflection and for each negative thought, substitute a positive thought. Write these down and repeat them when you feel critical about your body;
      5. Think of situations you avoid e.g. looking at your full length reflection and confront them. Look at other people’s bodies and note why you prefer your body;
      6. Make time to physically indulge yourself and as you do so alter negative thoughts to positive ones;
      7. Exercise for enjoyment. Prioritize your activities by rating them 1-10 for enjoyment.
    • Continue working on your diary.

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11. Competitiveness and Perfectionism
    • Most of our problems arise from failing, so learning how to fail without attacking yourself is useful in gaining more control over your mood. Without realizing it, because of the pressure to succeed, we can become competitive and perfectionist people who are daunted by the thought of failure.
    • Perfectionism leads to frequent disappointments which results in feeling low.
    • Perfectionism can lead to competitiveness when we want to be seen as superior and wish to avoid inferiority.
    • To find out in which areas of your life your competitiveness lies ask yourself which areas of your life you would not settle for being average and which concern you regarding what others possess, are achieving or doing.
    • A problem with perfectionism is that you evaluate yourself on the products of your activities and disregard your efforts.
    • Competitiveness and perfectionism can be directed at our self or at others or we may feel it is expected of us.
    • Another problem with competitiveness and perfectionism is that your internal bully often directs frustration and anger toward yourself.
    • You may become self-centered from perfectionism and competitiveness if you let your inner bully take control.
    • You may experience frustrative anger, anxiety or guilt at not succeeding, because of your negative thinking styles.
    • As a result self-attacking or attacking others may increase, leading to you feeling more low.
    • You need to consider how you cope with yourself and others when you cannot meet your ideal standards.
    • In order to identify your competitiveness and perfectionism think about an occasion when you did not succeed at something. What were your ideals regarding the matter? What were you hoping to achieve and why would that have been good? Were you afraid of inferiority or were you seeking superiority? Were you attempting to attain your own ideals or those dictated by others? Was your objective to gain the favour of others? Are you success orientated or do you try to avoid failure?
    • Praise yourself for even your little successes.
    • Examine your actions when you fail. Do you attack yourself or others? What do you say in these circumstances? Do you accept failure, if so why? Write these down to make things clearer for yourself. Next explore if you use types of negative thinking e.g. all-or-nothing thinking.
    • Learn how to fail so that you need not fear achieving success. Use your rational and compassionate mind to ask yourself firstly how you would advise a friend, then what you wish them to say to you. Can you find alternatives to challenge your negative thoughts and feelings?
    • Try to break things up into a manageable size and proceed in steps concentrating on your achievements rather than what you have been unable to do.
    • Set realistic standards, become tolerant of others’ mistakes and learn to identify what is ‘good enough’ and accept it.
    • Is your life pleasurable or do you not enjoy things? Can you complete one task today? Consider how you might obtain help from others?
    • Learn to accept yourself thus gaining confidence and enjoy your success.

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12. Assertiveness Training
    • The aim of assertive behaviour is to stand up for your legitimate rights and face others without putting yourself or them down.
    • Assertiveness training teaches you to increase the number and variety of situations in which you are assertive.
    • There are three types of interpersonal behaviour:
      1. Aggressive - you may be forceful in expressing your opinions, feelings and wants.
      2. Passive - your opinions, feelings and wants may be withheld completely or partly.
      3. Opinions, feelings and wants are stated with respect for the rights of others.
    • Make sure you are aware of your fundamental rights which include: asking for what you want; saying 'No' without guilt; not being perfect; being ignorant about something; being responsible for your actions; having your own perspective and emotions; being indecisive; choosing whether or not to deal with others' difficulties; expecting privacy, independence and success.
    • There are five steps to being assertive:
      1. What do you want? ;
      2. What is fair? ;
      3. Be clear in asking for it;
      4. Contemplate and be ready for the risks;
      5. Stay calm
    • Practice your arguments in advance and repeat yourself to get the message across. Be prepared to negotiate.
    • Think about situations in which you are not assertive and how you could change this and be assertive.
    • Write out a detailed description of problem scenes - note when and where the problem occurs; who is involved; what your difficulties are; how you handle it; your fear of what will happen if you are assertive; your goal.
    • To deal with a problem situation:
      1. Consider your rights and wants.
      2. Unless spontaneous action is required, arrange a mutually convenient time to discuss your problem with the other person.
      3. Define the problem as specifically as possible.
      4. Describe your feelings using 'I' messages, to give the other person an understanding of how important the issue is to you.
      5. Make your request in one or two simple but firm sentences.
      6. Give positive reinforcement to get what you want e.g. we'll be able to spend more time together. If this will be ineffective try negative reinforcement, describing the alternative way you will look after yourself if your wishes are not met.
    • You need to arrive at a workable compromise. Agree to review this after a specified length of time and if you are not both satisfied you can renegotiate.
    • Avoid being manipulated - techniques include:
      1. 'Broken Record' where you choose a concise assertive statement to say over and over to get your message across.
      2. Delay responding to a challenging statement until you are more prepared.
      3. Inviting criticism may reveal what is troubling the other person.
      4. When someone puts you down, acknowledge something you can agree with in their criticism and ignore the rest.
      5. You can change the focus, from discussing the topic to analyzing the interaction between the two of you.
    • In instances where you lack time you could use the short form assertiveness technique. Consider:
      1. Your thoughts - state the facts as: 'I think…'
      2. Your feelings - express as 'I' statements: 'I feel…'
      3. Your wants - specify behaviour change as: 'I want…'
    • You need to develop assertive body language. Practice the following basic rules in front of a mirror so that you learn how to apply them to problem situations:
      1. Maintain eye contact and an erect body posture.
      2. Speak clearly and firmly.
      3. Emphasize what you are saying with gestures and facial expressions.
    • Learn to listen assertively:
      1. Make sure you are both ready to listen.
      2. Listen giving the other person your full attention and ask them to clarify if necessary.
      3. Let the other person know you have heard what s/he has expressed to you.
    • Practice being more assertive in problem situations and consider how it makes you feel.
    • Role-playing is a good way to improve your assertiveness in a safe environment before trying it out in real life situations.

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13. Managing Anxiety
    • Anxiety prepares us to cope with stressful and dangerous situations. It is a reasonable and sometimes vital response, unless out of proportion.
    • Worry, fear and anxiety trigger the release of the hormone adrenaline resulting in bodily changes (e.g. increased breathing rate), psychological changes (e.g. change in thought and feeling) and behavioural changes (i.e. fight or flight).
    • The stress response is helpful in the short term to prepare us for physical action but if it becomes chronic or too much, difficulties can ensue.
    • In long term stress, bodily changes intensify to become unpleasant. Psychological changes, if sustained, result in worrying and negative thinking. Behavioural changes can magnify and become exhausting, cause physical or mental problems and be detrimental to good health.
    • Stress leads to the stress response and distress ensues, resulting in increased stress and this causes the stress response again and a cycle is created.
    • Continue to work on your diary and aiming for ‘targets to normal eating’
    • For anxiety linked to eating, you may need to learn to deal with the mounting tension through relaxation and distraction techniques.

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14. Stress Awareness Training
    • You need to monitor your stress and become familiar with what sets it off and the feelings, thinking and actions associated with the anxiety. You can do this by keeping a diary. When you feel anxious note the date and time. What was the event? Rate your distress 1-10 (1 is no distress and 10 is extreme panic). What caused your anxiety? What was your response to cope with the problem? Re-rate your distress.
    • After two weeks of monitoring your stress levels you should become aware of what triggers your distress, your bodily feelings and thoughts when distressed, how your distress levels vary with different situations, what you tend to do when distressed and what is the best way for you to cope with your distress.
    • Make two lists – one of short-term only coping strategies and the other of long-term coping strategies. You can refer to these when you feel stressed. Try to incorporate more of the long-term strategies into your set of coping techniques and attempt to gradually abandon your short-term methods.
    • Avoid turning to stimulants such as alcohol, caffeine and nicotine as coping methods. These have unpleasant effects in the long-term.
    • Study your diary to determine what drives your cycles of distress. Is it bodily, psychological, behavioural or social?

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15. Dealing With Bodily Experiences: Controlling Your Breathing
    • Hyperventilation – faster breathing occurs in response to exertion and stress. In the long-term this can be uncomfortable and cause unpleasant physical symptoms which trigger more anxiety and more hyperventilation. Another cycle of stress is set up and can result in a panic attack.
    • You can rectify hyperventilation by learning to control your breathing.
    • First practice lying down and later sitting or standing. Place one hand on your stomach and the other on your chest. Breathe in slowly through your nose until your lungs are full then exhale slowly through your nose. Breathing in and out counts as one breath – aim to take 8-12 breaths a minute.
    • In order to be effective you need to practice this exercise repeatedly.

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16. Dealing With Bodily Experiences: Relaxation
    • You need to develop relaxation into a skill you can use when you feel muscular tension due to stress.
    • Try to develop a routine and practice your relaxation exercises. Start by lying down and later you can try sitting or standing. Control your breathing.
    • Record your experiences noting the date and time. Rate your distress before the relaxation exercise, 1-10 (1 is tense and 10 is very relaxed). Which exercise did you use? Rate your distress afterwards. Make notes of the sort of day it was, your preoccupations etc.
    • Below are three exercises – only move to the next one when you are fully relaxed after a routine.
      1. Progressive Muscular Relaxation (PMR) – Breathe slowly and regularly as you focus on different parts of the body: feet – tense your feet then relax and repeat; legs – straighten your legs then relax and repeat; abdomen – tense your abdomen then relax and repeat; back – arc your back then relax and repeat; shoulders/neck – bring your shoulders up and in and press your head back. Relax and repeat; arms – stretch out your arms and hands. Relax and repeat; face – tense your face and bite hard then relax and repeat; whole body – tense your whole body then relax and repeat.
         After the routine if you still feel tense then repeat it then when you are relaxed think of something calming to relax your mind. Get up slowly and gently.
         You should practice PMR twice a day until you feel relaxed after the exercise.
      2. Shortened PMR – You can miss out the tensing and go straight to relaxing the different muscles. When you have achieved this you can progress to using the routine at other times and places.
      3. Simple Relaxation Routine – Identify a word, object or scene you find calming. Sit comfortably and close your eyes. Be aware of your breathing as you inhale through your nose. As you exhale, think about your calming mental image. Continue this until you feel relaxed. You should practice this exercise frequently.
    • When you have learned to relax using the three exercises you can start to use the skills throughout the day. Use something to remind you regularly to relax. Apply your relaxation skills whenever you need to use them in response to physical tension.

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17. Dealing With Psychological Aspects: Distraction
    • A cycle of mounting anxiety is set off by alarming thoughts and images. You can break this cycle by distracting yourself.
    • Physical Exercise – If you keep active you are less likely to be preoccupied by worrying thoughts.
    • Refocusing – Distract yourself by focusing on things around you e.g. listening to others’ conversations or studying how someone is dressed.
    • Mental Exercise – Formulate a phrase, picture or mental exercise that distracts you e.g. redesign your home, imagine your dream home in detail or recite poetry.
    • Develop a set of distraction techniques for different occasions that are suited to your needs e.g. If you get stressed at interviews then physical distraction will not be helpful.
    • Make two columns – in one write down the situation causing anxiety and in the other your chosen distraction method.
    • Practice your distraction techniques when you are not anxious and try to catch your anxiety at an early stage.

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18. Managing Your Time
    • Good time management requires being aware of:
      1. Your needs and strengths – list these opposite each other.
      2. Your standard procedure – find out how you use your time at present by keeping a record of how you spend your time. From the record you will be able to work out the best way of working. Try to get a balance of work tasks and include breaks.
      3. Your priorities – identify and rank in order of priority the different areas of your life. Consider the time you allocate to each and what is realistic and necessary. Perhaps others are making demands of you that you need to be more assertive about?
      4. Setting reasonable goals – keep in mind the important areas of your life when pursuing goals. Clearly define your goals so you know when you have achieved them. Some goals will need to be broken down into more manageable steps.
    • Once you know the above you can draw up a new more efficient schedule. Use an organizer and list long-term (within six months), medium-term (within a month) and short-term (within a week) goals. Set aside time each day to organize. Try to do a ‘To do’ list of prioritized tasks every day. Plan flexibly and review every month.
    • Delegating – giving over responsibility with authority, to others for appropriate tasks, is part of good time management.

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19. Sleep Management
    • The length of sleep necessary varies from person to person.
    • Worrying will prevent you from sleeping.
    • You need less sleep as you get older.
    • Sleep is affected by mood, stress, food, alcohol, exercise and medicines.
    • In the long-term, sleeping tablets are not helpful and can be addictive.
    • You can manage your sleep problems by changing your behaviour rather than resorting to medication.
    • Keep a sleep diary for several nights to ascertain if you have a problem. Note the date and anything that might affect your ability to sleep e.g. your activity before retiring. If you have waking episodes, note your activity to restore sleep. Was it helpful? Next day note the number of hours of sleep you managed to get and rate how alert you feel 1-10 (1 is dull and sleepy and 10 is very alert). Rate your performance that day 1-10 (1 is poor performance and 10 is performed well). If you do have a problem the following suggestions might be helpful:
      1. Analyze your sleep diary to see if poor sleep is due to stress and is likely to get better as this eases; are there behaviours which result in poor sleep that you could change?; identify helpful and unhelpful ways of coping and avoid the latter.
      2. Introduce pleasant smells into your sleeping environment to help you relax e.g. potpourri or lavender oil.
      3. Try to relax an hour or two before you go to bed. Keep your daily stress low and seek counselling or the support of friends if you feel the need. Exercise during the day. Avoid caffeine, nicotine and alcohol and try a warm milk drink before bed. Make sure you are not hungry before retiring as this will keep you awake. · Ensure you have a quiet bedroom and a comfortable bed and have emptied your bladder before trying to sleep. Use your bed only for sleeping and set an alarm so you wake regularly each day. Avoid naps during the day.
      4. If you sleepwalk you are advised to discuss this with your doctor as it can be dangerous.
    • To cope with disturbing dreams you could try:
      1. Constructing a positive ending to your disturbing dream and mentally practicing this alternative ending several times before sleeping;
      2. Practicing beforehand what you might say if the dream occurs;
      3. Keep water and a towel by your bedside to wash your face with if you wake up sweating - this will help you re-orientate;
      4. Keep a notepad and pencil within reach so you can record your dreams but beware of reading too much into their interpretation.
    • Relaxed Breathing Method:
      You could try the following method of relaxed breathing to ease tension and promote sleep:
      1. Ensure you have some time to yourself and push your worries to one side;
      2. Sit or lie comfortably and close your eyes with your arms by your side;
      3. Concentrate on breathing naturally;
      4. Place your hands on your stomach and breathe in deeply and hold for a few seconds feeling your stomach rise. Breathe out and feel your stomach contract. Repeat and as you breathe out think of a relaxing image or sound. Continue doing this until you feel thoroughly relaxed;
      5. Count back from 10 then open your eyes and feel how relaxed you are now. Slowly get up and resume normal activities.

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20. Problem Solving
    • Problems of any sort can exacerbate a person’s eating difficulties.
    • The problem-solving approach can be useful in these cases. You learn to focus your thinking and find solutions to your problem. There are six steps in problem-solving:
      1. Define the Problem – Be specific and try to break the problem into more manageable tasks. Do one task at a time. Choose your task and specify your goal.
      2. List Solutions – Try to write down as many ideas, to solve your problem, as you can.
      3. Evaluate the Pros and Cons of Each Solution – Consider your solutions and reject the unsuitable ones. List the remaining solutions in order of usefulness.
      4. Selecting a Solution and Planning Action - Choose your first solution and decide how you will put it into action. Rehearse your task and make sure you have a back-up plan in case your task does not go as planned.
      5. Do it - Attempt your solution.
      6. Review the Result of the Solution – If your solution is successful try to understand why it was so. If your solution is unsuccessful try to comprehend why it did not work. Praise yourself for having tried and choose your next solution from your list.
    • Accept that you will struggle to overcome your eating problem and not succeed all the time. You need to consider all the little successes and reward yourself for this progress.
    • If you feel you are incapacitated by depression seek medical help to improve your mood so that you can make better use of this advice.
    • By dealing with your relationship problems using the problem-solving approach it will be possible for you to break negative cycles affecting your eating. You may feel that resolving your relationship problems requires professional help.
    • Often when people with eating problems feel bad due to circumstances such as wearing a tight dress, they feel fat and want to concurrently diet and eat. You need to identify and resolve the real problem.
    • Anorexics can have great difficulties when feeding other people and in these situations should avoid anything they know will cause problems.

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21. Dealing With Interpersonal Relationships
    • Interpersonal relationships may have caused AN or may be preventing you from recovering – in any event interpersonal relationships will be affected by AN.
    • You need to understand your personal relationships and be able to deal with them effectively.
    • Draw interpersonal maps – one for before you developed AN and the other for afterwards:
      1. How your interpersonal relationships are at present;
      2. How your interpersonal relationships might be now if you did not suffer from your emotional problem;
      3. How your interpersonal relationships will be in 10 years if you continue to suffer from your emotional problem;
      4. How you would ideally like your interpersonal relationships to be.
    • These will summarize all your relationships and allow you to recognize any changes you may desire.
    • List all your important relationships and put yourself in the middle of the map in a circle.
    • Place each person’s name in a circle on the map, around you in the middle – the closer the relationship to you, the closer the circle to you.
    • Join these circle’s to you in the middle with an arrow outward if it is you mainly giving; an arrow inward if you are mainly receiving; a two-way arrow if giving and receiving is balanced; a question mark if you are unsure.
    • You could also draw maps for how you would ideally like your interpersonal relationships to be; how your interpersonal relationships might be now without AN; how your interpersonal relationships will be in 10 years if you still have AN.
    • Examine these maps noting any differences and set yourself goals to make any desired changes to your relationships.
    • For each relationship ask yourself:
      • who initiates and terminates contact;
      • are you happy with how often you see this person? ;
      • who decides what to do or what to talk about? ;
      • is there a balance between giving and receiving? ;
      • do you want to alter the relationship in anyway?
    • Consider questions such as:
      • who could I confide in and get advice from? ;
      • who would be there for me if I fell ill? ;
      • who would lend me money at very short notice?
    • Next time you have contact with each person, examine the relationship – participate and observe. Were your predictions correct? – If not, what was different?
    • When you have a complete picture of your relationships, think about how you maintain them and in what way you want to change your relationships.
    • Two important reasons for making changes are:
      1. A balanced and supportive social network is necessary for your well-being;
      2. The development and maintenance of AN is linked to feeling out of control – by altering your relationships but avoiding being controlling, you may increase your sense of control.
    • Start by making small changes and monitoring progress. You could also try discussing what you have learned about the relationship with the individual.
    • Continue working on your food diary and aiming for ‘targets to normal eating’.

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22. Removing The Obstacles To Intimacy
    • Record and examine closely the things that prevent you from achieving intimacy with someone. Note your thoughts and reactions when you distance yourself from a friend or end a relationship and make an analysis e.g. are you overgeneralising?
    • Social inadequacy can be an obstacle to intimacy. Apply your assertiveness skills to your social and work life and observe how socially skilled people handle situations in particular difficult ones. Rehearse your social behaviours so that you are comfortable with them.
    • Try to grasp your anxious thoughts, examine them closely and if required, challenge them. What are your anxious thoughts? Is your outlook biased – are there misjudgments? Consider the evidence to support and discount your thoughts.
    • See ‘Overcoming Social Phobia’ in the Forward Counselling Advice Service.
    • It is possible to become over-intimate and make ourselves vulnerable to exploitation. Trust can be given in a series of stages and you can fluctuate as to how much you trust someone.
    • Communication is necessary for all relationships. Record the feelings which threaten your relationship (e.g. jealousy) and grasp the automatic thoughts. Analyze them and find alternative ways of dealing with the situation.

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23. Conclusion
    • Be prepared for set backs. The skills you have learned need to be continued to be applied.
    • Try writing distracting activities on small index cards to keep at hand for when you need them.
    • Do not be discouraged if you notice little change in your behaviour – finding alternatives to your usual coping methods will be difficult.
    • Keep up the effort because freedom from AN will enable you to cope better with life, in the future.

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