Overcoming Bulimia Nervosa

1. What Are Bulimia Nervosa and binge-eating?
   • 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 food 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 calorie 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 weight and shape, 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. 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.
   • 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 to this distorted body image.

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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.
   • 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, weight and shape; worrying in situations where they feel particularly fat or where food is available.
   • Anger may result in: taking laxatives or hitting themselves as self-punishment; cutting themselves as self-punishment and to release tension, prior to or preceding 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 food 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.
   • Physical effects of binge-eating and compensating for over eating include:
   • A sense of being full and bloated after a binge, breathlessness, abdominal pain and general digestive problems such as constipation and diarrhea.
   • 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:
     1. erodes the teeth;
     2. the salivary glands swell causing a puffy face which may be interpreted as weight gain, leading to further vomiting;
     3. the throat may be damaged and become infected;
     4. violent vomiting may cause the esophagus (the tube joining the mouth to the stomach) to rupture – this is a medical emergency;
     5. the esophageal 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;
     6. the process of vomiting, drinking and vomiting again causes electrolyte disturbance (an abnormality in the balance of body fluids and body 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 the disorder. 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.
     • 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:
     • Favorable 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 over eating. Depressed mood and alcohol consumption are also factors which produce this paradoxical behaviour or counter-regulation effect in dieters.
     • Some people over eat in response to stress, anger or misery.
     • 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 concerns about weight and shape leads to dieting and compensating for over eating e.g. self induced vomiting. A vicious circle results because vomiting and 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.
     • 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 antidepressant drugs used to treat bulimia nervosa are: 1) monoamine oxidase inhibitors (e.g. phenelzine); 2) tricyclic antidepressants (e.g. imipramine, desipramine and amytriptyline); 3) serotonin reup-take inhibitors (e.g. fluoxetine 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 2/3 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 antidepressant drug and psychological therapy may be considered although not always necessary due to established benefits of cognitive behaviour therapy.
   • There are four levels of treatment of increasing intensity:
     1. supervised self-help;
     2. antidepressant medication and supervised self-help;
     3. individual cognitive behaviour therapy;
     4. 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 nervosa and bulimia over binge-eating that is not associated with compensatory behaviours.
   • Those suffering from anorexia as well as bulimia may find this advice is detrimental and should see ‘Overcoming Anorexia Nervosa’ in the Forward Counselling Advice Service.
   • 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 interest 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 set backs with the given advice. Progress can 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.
   • 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.
     

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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:
     1. Record the time food is eaten;
     2. Record with reasonable precision all food and liquid consumed during the day. Do not record the calorie content and put in brackets any episodes of controlled eating which would constitute a ‘normal meal’;
     3. Record precisely where the eating took place;
     4. 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. You need to record all food eaten, even when you are binge-eating – try to do this immediately after eating;
     5. Record any episodes of vomiting, laxative or diuretic misuse or excessive exercise;
     6. Record the circumstances in which eating occurred, your thoughts and feelings especially after episodes of binge-eating.
     7. Record the occasions when you weigh yourself and check your shape.
   • Review your monitoring sheets each week to try to 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 over all and will not become fat as you might fear at first.
   • It is important that you eat only at planned times and stick to this plan since you cannot at this stage trust your feelings of hunger.
   • Write down a plan of the 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, supper, 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 may 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 you will lose control and binge.
   • To decide how much to eat at the planned times 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 content 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 feel 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 don’t binge you won’t feel the need to vomit. Vomiting encourages overeating so if you do 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.
   • Some people vomit after eating anything at all. Try dividing the day into six parts and eating the planned meal for that 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 weight and shape but regular checks on your weight 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 avoiding 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 leftover 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 should 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 time 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 and 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 maybe 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 food.
   • If you are to progress you need 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: fasting; eating too little; avoiding particular types of food considered to be ‘binge’ foods.
   • The meal plan eliminates fasting and you should experiment to find what constitutes a ‘normal’ amount of food to you as this varies from person to person. You need to 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. You need to realize that you do not 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 food you avoid because they are ‘fattening’ or trigger binges. Put the most ‘forbidden’ food at the top of the list and make a hierarchy so that the least ‘fattening’ food is at the bottom. Divide the hierarchy into three groups – foods which cause minor, moderate and extreme difficulty.
   • Staring 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 can feel that 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 a hierarchy starting with the least difficult to the most difficult and work your way down the list using the principles you have learned and practice coping in these situations in a safe environment until you feel you can cope in all circumstances.

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10. 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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11. 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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12. 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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13. 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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14. 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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15. 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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16. 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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17. Problem Solving
    • Problems of any sort can cause a person with eating problems to overeat.
    • The problem-solving approach can be useful in these cases. You learn to focus your thinking and find solutions to your problem instead of overeating. 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 you 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.
    • Bulimics can have great difficulties when feeding other people and in these situations should avoid anything they know will cause problems. They should try not to force food onto people and arrange for someone to get rid of leftovers.

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18. 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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19. Dealing With Interpersonal Relationships
    • Interpersonal relationships may have caused bulimia or may be preventing you from recovering – in any event interpersonal relationships will be affected by bulimia.
    • You need to understand your personal relationships and be able to deal with them effectively.
    • Draw interpersonal maps – one for before you developed bulimia 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 bulimia; how your interpersonal relationships will be in 10 years if you still have bulimia.
    • 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. 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.

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20. 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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21. Conclusion
    • Your concern about your weight and shape 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 weight and shape.
    • Try not to judge self-worth in terms of weight and shape as this leads to eating problems. Consider how important weight and shape are in how you value others and how they value you – It is most likely that weight and shape rank very low on both your lists of valued attributes in each other.
    • When you attribute negative events or feelings to your weight or shape try to look for other more rational perspectives.
    • Perfectionism can result in guilt and self-criticism which make you feel bad and causes concern about weight and shape leading to dieting and binge-eating. Try to treat yourself as you would a friend.
    • 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.
    • Particularly distressful events can lead to a lapse and you may binge but you must realize that there were extenuating circumstances and 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 and your confidence will return and you will be at ease with eating.
    • Be alert for when you feel bad about your weight and shape and want to diet – avoiding such feelings and preoccupations are your way forward

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