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Overcoming Bulimia Online Workbook 1 Introduction and What is Bulimia? Dr. Chris Williams Dr. Susan Dunt Professor David Cottrell Dr. Pat Harkin Revised and updated in collaboration with Dr. Ulrike Schmidt, Institute of Psychiatry

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Introduction The Overcoming Bulimia Online (OBO) course has been designed for those with bulimia and related eating disorders. We hope you find the course useful and effective. These workbooks have been designed so you print and use them whilst working through your sessions. This will enable you to: • • • •

Have a written copy of everything that is covered in the sessions. Make key notes whilst you are completing the session. Use it to help you remember what you have learnt each session and how you answered questions set at that time. Use it to help you with the assignments you will receive at the end of each session.

As you work through the course you be asked to complete certain assignments between the sessions. This will help you to remember what you have learned and put it into practice. This will always be for a purpose to help you practice a skill, learn something new or gather important information. Completing these tasks is a vital part of getting better. By doing this you will be able to find out which beliefs and behaviours might be adding to your problems.

Course Outline There are eight sessions to the course which each take approximately 40 minutes to complete. You can only complete one session at a time, this is so you can complete your homework assignments and reflect on what you had learnt in your previous session. 1). Introduction: What is bulimia? In this session you will learn about bulimia and its physical and emotional consequences. You will be introduced to the Vicious Circle of Bulimia, which will help you to understand how you feel and behave and how to change this. 2). Understanding why I have bulimia In this session you will learn why people develop eating disorders, how food and relationships influence each other and how to increase your motivation to change. 3). How do I change? In this session you will learn how to fight craving for food and how to establish a new eating pattern. You will be introduced to the rules for healthy eating. 4). The role of thoughts in bulimia In this session you will be introduced to ways of identifying and challenging extreme and unhelpful thinking. What you think about food, your shape and weight, can affect how you feel emotionally about yourself, and also affect your behaviour. Identifying and challenging these extreme and unhelpful thoughts will help you to overcome your bulimia. 5). Learning new skills: Assertiveness and increasing activity In this session you will learn about assertiveness. This will enable you to take more control of your whole life and the decisions that you make. By feeling more in control

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of your life, you will grow in confidence in the ways that you cope with all areas of your life. 6). Learning new skills: Problem solving In this session you will learn a step by step method of dealing with your practical problems. Sometimes we can all feel overwhelmed by our problems whether these are difficulties such as money worries, or problems in relationships, it is possible to learn effective new ways of dealing with them. This session will enable you to deal with your day to day difficulties as well as teaching you a method of tackling larger problems in your life. The session will also help you identify and challenge extreme and unhelpful thinking that might be undermining you and adding to your problems. 7). Living life to the full. In this session you will learn how to identify whether avoidance is a problem for you and how to overcome it. Sometimes bulimia can cause people to avoid areas of life; this may range from the avoidance of certain activities such as swimming, and includes stopping or reducing activities that seem scary or too difficult. This session will show you how to begin to do these things again. 8). Planning for the future. By this stage you will have learned many new things about yourself and made changes in how you are. This session identifies what you have learned and helps you plan for the future so that you can help stay well. You will be helped to devise your own personal plan to cope with future problems in your life so that you can face the future with confidence.

Format of the OBO course Each session on the computer will have the following format: • • •

Firstly an opportunity to review the previous sessions: once you have completed a session they become ‘revision sessions’. Secondly an outline of what the session contains and what you will learn from the session. A relaxation training session. This is because tension and stress can add to your problems. You will learn an effective form of relaxation called Anxiety Control Training (ACT) at the end of each session. You are likely to find this most helpful if you also practice it between sessions using the downloadable audio files, which can be found under the ‘Downloads’ tab of the OBO website.

Change will not happen all at once, but slowly over the weeks you will find that the way forwards becomes clearer. Changing unhelpful eating habits takes time. We hope that everyone who finishes the course will have moved forwards. This is a time to learn about yourself and to change. Change involves a persistent effort in examining your attitudes and beliefs about weight and the underlying issues which may lead to an eating disorder. To do this can be challenging. Change takes time and effort and it will take courage to try out some of the suggestions you will learn about over the next few weeks. Progress depends on committing yourself to using the package, putting into practice what you have learned

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and deciding to change yourself. You will not be asked to do anything that is too difficult, but you will be expected to push yourself at a pace that is comfortable to you. If you commit yourself to the process of changing as a person, you will be able to change. After one or two sessions you may be tempted to give up. This can occur for a number of reasons. Sometimes you may feel disheartened and think that nothing will ever change. These feelings are normal and understandable. It is sometimes very tempting to give up and withdraw from the problem. The very fact that you have a problem with eating makes it difficult to tackle. Change can be challenging, but in the end your hard work will pay off.

If you feel worse: The package asks you to think about bulimia and its causes. It has been designed to do this in a way that is sensitive and it is hoped helpful. However, sometimes if for whatever reason you feel worse when using the package, please speak to your health care practitioner. If you feel hopeless or like life isn’t worth living: There are times when we all feel down and low in mood. This is a part of life. However, if you feel hopeless or like life isn’t worth living, either before you start using the package or during the time you are working through the package, there are a number of ways that you can get help. The OBO website does not provide direct clinical support. If you are in imminent danger of hurting yourself you MUST get immediate professional help which we CANNOT provide here. If you are looking for support or advice urgently, there are a number of services you can approach: •

Your own GP

•

Call your accident and emergency department at your local hospital

• The Samaritans (24 hours) Telephone 0845 7909090 or email [email protected] • Beat Helpline (UK’s leading eating disorder charity) Telephone 0845 634 1414 or email [email protected] Opening Hours Monday to Friday 4.30pm – 8.30pm , Saturday 1pm – 4.30pm • Beat Youthline Telephone 0845 634 7650 or email [email protected] • Bodywhys (Ireland’s eating disorder charity) Telephone 012834963 (for England, Scotland and Wales 00353 12834963) Helpline: 1890 200 444 • NHS 24 for Scotland (24 hours) Telephone 0845 4 242424 •

NHS Direct for England and Wales (24 hours)

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Telephone 0845 4647 • Breathing Space (Scotland only: evening until 2am) Telephone 0800 83 85 87

It doesn't matter who you are - If you are in crisis, despairing or suicidal, contacting one of the above agencies can make all the difference. You can speak in total confidence about anything that is troubling you.

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Session 1 Introduction: What is bulimia? In this session you will learn: • • • • •

What bulimia is. The helpful and unhelpful methods that people use to control their weight. The Vicious Circle of Bulimia – this describes the way that some of our reactions when facing bulimia can actually worsen how we feel. The physical, psychological and emotional consequences of bulimia. A relaxation exercise which will help you to cope better with stressful situations if you practice it on a regular basis.

What is bulimia? The key features are: •

Craving for food, which can lead to:

-

Repeated bingeing or eating with a sense of loss of control. Regret or guilt that then leads to behaviour to reverse the effects of overeating or bingeing.

Weight control methods Do you use any of the following methods of weight control? (please circle your answer) 1). Dieting that at times can be extreme (miss meals, self-starve etc.)? 2). Self-induced vomiting – do you deliberately make yourself sick? 3). Use laxatives on a regular basis? 4). Use other medications or dietary aids to lose weight? 5). Use excessive exercise to lose calories rather than for fun?

Yes Yes Yes Yes Yes

No No No No No

In the next section of the workbook, a model is described that shows how craving, bingeing and unhelpful reversing behaviours such as vomiting and using laxatives to lose weight link together.

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Let’s now try to identify whether your eating fits this pattern.

Identifying the events that lead up to the overeating/binge The following questions will begin to help you work out your own Vicious circle of bulimia. Think about a time recently when you have overeaten/binged or lost control of your eating. Time: Try writing down the answers to these questions. Identifying the Events that led up to the overeating/binge (write down your answer next to each question): What time of day was it? Where were you at the time of the overeating/binge?

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Were you alone? Had anything happened (e.g. an argument or had something upset you)? Had you had any alcohol to drink? Were you feeling hungry? Were you occupied? Had you been dieting or missing meals?

Emotional changes leading to the binge/overeating. Think about what emotions you noticed leading up to the overeating/ bingeing. Read through the following statements and then give them a score out of 10: • I felt happy. 0---------------------------------------------------------------------------------------------------------10 Strongly disagree

Strongly agree

• I felt sad and depressed. 0---------------------------------------------------------------------------------------------------------10 Strongly disagree

Strongly agree

• I felt anxious and stressed. 0---------------------------------------------------------------------------------------------------------10 Strongly disagree

Strongly agree

• I felt guilty and bad about myself. 0---------------------------------------------------------------------------------------------------------10 Strongly disagree

Strongly agree

• I felt angry at myself. 0---------------------------------------------------------------------------------------------------------10 Strongly disagree

Strongly agree

• I felt angry or irritable about someone or something else. 0---------------------------------------------------------------------------------------------------------10 Strongly disagree

Strongly agree

• I felt empty/no emotions. 0---------------------------------------------------------------------------------------------------------10 Strongly disagree

Strongly agree

Identifying the nature of the binge

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What did you eat at the time (write down your answers next to the food types below)? Fatty Foods (e.g. ice cream, butter, margarine, full fat cheeses):

Carbohydrate (e.g. cake, biscuits, jam, honey, sweets, crisps, bread, potato, rice, pasta etc.):

Proteins (e.g. meat, cheese):

Alcohol (lager, wine, beer, spirits, “alcopops”):

Other:

Identifying what you thought immediately after the binge What did you think about yourself after the overeating/binge? Consider what you thought about: •

Yourself?

•

How others see you?

•

What might happen in the future?

•

Your own situation?

•

Your own body, behaviour or performance?

•

Were there any painful memories from the past?

•

Did you notice any images or mental pictures in your mind? Images are an important type of thought and can have a powerful impact on how you feel.

Circle Yes or No to the thoughts below that you may have experienced: • • • • • •

“I’m bad.” “I’ve blown it.” “I’ll never get better.” “I hate myself.” “Others won’t like me.” “I’m fat.”

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Yes Yes Yes Yes Yes Yes

No No No No No No

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Identifying what you felt immediately after the binge was over How did you feel immediately after the overeating/binge? (Circle your answer to each question): • • • • • • • •

I felt unhappy I felt sad and depressed I felt anxious and stressed I felt guilty and bad about myself I felt angry at myself I felt angry or irritable about someone or something else I felt empty/no emotions Something else?

Yes Yes Yes Yes Yes Yes Yes

No No No No No No No

Identifying altered behaviour to reverse the binge Below is a list of common reversing behaviours that people may use to reverse the impact of overeating/bingeing. Did you do any of these after this recent binge? (Circle your answer to each question): • • • • • •

I decided to diet again (miss meals, self-starving etc..) Yes No I made myself sick Yes No I used laxatives Yes No I used other medications/dietary aids to lose weight. Yes No I exercised in order to lose weight (with a view to losing calories rather than for fun) Yes No Something else?

Next copy from the computer screen your responses which were summarised by the computer. Think about the vicious circle. Does it seem to explain what happened? Are there any other factors that need to be added? If so, try to add them.

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Understanding why you are overeating/bingeing/losing control over your eating • •

• • • •

Overeating/bingeing may lead to feelings of guilt and also strong self hatred. The guilt and regret often then leads to reversing behaviour (such as making yourself sick by vomiting, or choosing to diet or miss meals. You may also use medication or drugs to reduce weight or choose to do excessive exercise with a view of losing weight rather than to be fit). The problem is that the reversing behaviour actually keeps the circle going by further increasing your craving. The increased craving encourages further bingeing. Because of this, the vicious circle needs to be broken in order for you to get better A key to doing this is to realize that it is better not to try to reverse the overeating/bingeing in the first place

The Physical consequences of bulimia The next three tables summarise the information available in the computer program. Have you noticed any of these problems in your own life? Do I have

Cause

this? Teeth surfaces stained or uneven?

Feeling swollen or bloated?

This may result from self induced vomiting or excessive use of dieting drinks. This can cause erosion of the enamel on the surface of the front teeth caused by the acid from the stomach or dietary drinks. Such changes if noticed at particular times of the day may be due to changes in body fluids as a result of vomiting or use of laxatives or water tablets. It may also sometimes be caused by being overly focused on how your body feels. It does not reflect changes in weight or indicate that you are fat.

Periods irregular or

This may be due to hormone imbalance

absent?

which may be caused by an altered diet. Sometimes an absence of periods may also occur id dieting has led you to be far below a healthy weight range.

Tiredness and fatigue?

This may be due to low calorie intake and generally a poor diet.

Poor quality of skin (red

This may be low vitamin intake in a poor diet.

blotches or spots)?

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Palpitations of the heart?

Vomiting very frequently can cause low potassium levels in the bloodstream and these may result in heart problems. In extreme cases, it can even result in heart attack or sudden death. Eating a balanced diet can help prevent this. Talk to your doctor if you are concerned and would like a blood test.

Swelling of the ankles or

This may be due to low protein in the

legs?

bloodstream causing fluid to collect in the legs.

Swelling of the glands

This may be due to your salivary glands

under the jaw and in front f

working over-time as a result of overeating/

the ear making your face

binging and vomiting.

look puffy?

Psychological problems in bulimia

Do I have

Cause

this? Depression or guilt?

Dislike of self?

Tension, stress?

irritability

and

Poor concentration?

Sudden bouts of severe anxiety or panic?

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This is often a major problem. When people are feeling down this can sometimes make them feel change is impossible. It causes feelings of sadness, failure and hopelessness. Sometimes it can also reduce your enjoyment in life and cause you to feel tired all the time. This can be part of a long-standing problem of low confidence and low self esteem. Such feelings are common in bulimia, and may be helped by this package. It could be that you are suffering from anxiety. This can lead you to feel upset, irritable and tired. Your sleep can become poor and you may find your concentration worsens. This is a common problem in bulimia. Sometimes people find themselves becoming very forgetful. Anxiety can affect people's thinking (with worry or panic), their body (feelings of tiredness, irritability, tension, sweatiness and clamminess) and their behaviour (leading to avoidance of stressful things). You will begin to learn a relaxation technique today to help you relax your body. One of the sessions will

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help you alter unhelpful thinking and behaviours in anxiety. This is a common problem in bulimia and may be closely linked to your eating pattern.

Sudden and intense mood swings?

Relationship problems in bulimia

Do I have

Cause

this? Fear of going out?

Living a lie?

Relationship problems?

Lack of money?

Problems with employment?

This is an indication that you could be suffering from a phobia with a panicky fear that always occurs in certain situations and leads you to avoid situations like mixing with others or going shopping in future. Problems such as these are covered later in this package. Many people find themselves being very secretive or ashamed of their bulimia. This worsens feelings of poor self-esteem. Sometimes feelings of depression, low self confidence, anxiety or irritability can affect how you relate and cope with others. You may find that you are spending too much money on food, or go on shopping sprees. Bulimia may also affect your ability to earn a living. Many people with bulimia find it affects their ability to work in jobs. This may be the result of feeling ill, or losing confidence in your relationships with others.

Measuring your emotions A commonly used scale for measuring anxiety and depression is the Hospital Anxiety and Depression (HAD) Scale. You will be asked to fill this in each week and record your scores so that you can see any changes in how you feel. A normal score is 8-10. Scores higher than this level indicate you may be suffering from problems with anxiety or depression.

Anxiety Control Training As part of the program, you will begin to learn new ways of coping with the emotions that may lead to bingeing. Feelings of stress and tension can be very important. Dealing with anxiety by identifying unhelpful beliefs and behaviours will be the focus of a later session. In the mean time, you will experience a short session of relaxation which uses a tried and tested method of relaxation called Anxiety Control Training (ACT).

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Learning how to relax is like learning any new skill, it takes time and practice. For the first three sessions of the course you will learn the key skills of relaxation. In later sessions, you will then take this onto the next level of applying these skills during times when you feel anxious in everyday life. You will receive a tape recording of ACT. We’d encourage you to use it once or twice a day at home. You may find it difficult to relax at first, but try to persevere. You will eventually succeed.

Summary In this session you have learned: • • • • •

What bulimia is The helpful and unhelpful methods that people use to control their weight To begin to identify your own Vicious Circle of bulimia About the physical, psychological and social/relationship consequences of bulimia. The Anxiety Control Training approach

Putting into practice what you have learned this week You have now made the first steps in changing yourself using this package. Change will not occur all at once. First we must work out together why you are overeating and help identify the best ways to change this. This may take several weeks. Also, learning how to relax can take time. Normally, it takes some three to four sessions until the benefits of relaxation begin to show. Stick with the approach. It can help you get better. In order to help you to learn more about how to overcome your problems, a central part of the treatment approach is to ask you to take part in several tasks to complete during the week. These are essential to help you to get better. They mean that you are thinking about overcoming your problems on each day of the week as well as the treatment session. Over the coming week, please can you: • • •

Practice your ACT relaxation exercise by playing the tape at least once each day. Also plan to read through your workbook and think about how the principles apply to you. Finally, choose two episodes over the next week where you overeat or binge and summarise the impact on your thinking, feelings and behaviour in the workbook. Use the next two pages to think about your own vicious circle.

If you have difficulties with this, don’t worry. Just do what you can. Do not be disheartened if your eating difficulties continue this week. That is quite normal-it takes time to change. We must first start by working out why your bingeing is occurring. Over the next two weeks we will start to look at how to change this.

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Working out my own vicious circle • • • •

What led up to the binge? What did I eat? What did I think and feel afterwards? Did I use any reversing behaviours?

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