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Cognitive-behavioral treatment for bulimia: stage one COGNITIVE-BEHAVIORAL TREATMENT FOR BULIMIA: STAGE ONE
In the first stage the patient's main goal is to return to a pattern of regular eating. We want to establish a routine whereby she plans to eat three or four meals per day and possibly? two planned snacks. .
The key here is planning. A patient should know w due to eat next. She shouldn't skip meals, nor should she re ? on her appetite to tell her when to eat. If her plan calls for her to eat lunch at one o'clock, then she should do so, eating everything she planned to eat whether she feels hungry or not. She shouldn't snack unless the snack is part of the plan. Of course, the woman should not go for long periods without food. She shouldn't skip breakfast, for example.
Sticking to the plan takes priority over other activities. It's okay to accept dates, for example, but the patient must structure her social life around her meal plan. Her schedule may change on weekends, but she needs to plan those changes carefully.
The content of meals is less important than the regular pattern of meals during this phase. I urge the patient not to count calories, for instance. Instead she should eat average-size portions. She should wear loose clothing when she eats, since feeling constricted can lead to feelings of fullness. Here are some other helpful hints on controlling eating:
Tips for controlling eating
• Don't engage in other activities while eating: Don't watch TV, read, talk on the phone, do
homework and so on
• Restrict eating to one room of the house
• Limit food available when eating. Discard leftovers. Practice leaving some food on the plate.
Limit supplies of binge foods in the house; keep "safe" foods around instead
• Plan food-shopping expeditions. Make a shopping list and stick to it. Don't shop when hungry.
Carry just a little money when shopping, especially if you feel you aren't in good control
• Buy foods that need a lot of preparation, rather than those that can be eaten immediately
• Get rid of laxatives and diuretics
• Discard clothes that are too small
• Make adequate plans for your time - too much or too little unstructured time increases the
possibility of bingeing
If a patient eats too rapidly, she needs to slow down. Satiety signals need a little time to take effect. One tip: Put the fork down between mouthfuls and swallow before taking the next bite. It helps to savor food, pausing once in a while to decide whether or not to keep eating. I ask patients not to drink a lot of fluids during the meal, since doing so can exaggerate the feeling of fullness.
At first a patient may feel full after eating very little. Such feelings may trigger the urge to vomit. We work together to create a list of alternative activities so that she can distract herself and counteract these urges. One such list might include the following:
• Make a list of friends’ names and telephone numbers and call them when urges strike
• Visit friends
• Exercise (moderately)
• Go to a movie
• Take a bath or shower
• Write a letter
• Garden
• Knit or sew
• Read
• Listen to music
During this first stage the patient needs to keep checking on her progress. She should evaluate her eating daily. If she is successful, she needs to praise herself. On the other hand, she shouldn't overreact to failure. She needs to avoid turning a small slipup into a major catastrophe.
Once regular eating patterns return, her binge frequency should drop. The patient can then begin to examine the causes of her bingeing. Does she eat to relieve anxiety or depression? Is she bored? Does eating bring on sleep? Is she trying to compensate for something (perhaps even a monotonous diet)? Is purging self-punishment, or a way of expressing anger that she should direct at other people?
We also talk about situations that may contribute to the problem. Does she keep too much food in the house? Does her home environment interfere-is there too much stress or chaos?
One way of keeping track of these elements is through the food diary. The patient uses these sheets to record her feelings and actions connected with food. The food diary is a crucial element in therapy, offering a window on the patient's behavior. The vital information on these sheets becomes the raw material for our therapy sessions.
During the first stage of therapy, we work out a plan for keeping track of the patient's weight. Weighing too often can lead to anxiety and obsessions about weight. As I mentioned, everyone has day-to-day fluctuations in weight. For a patient, a slight rise can trigger panic and a sense of failure. These feelings may cause her to give up, leading her back down the path of bingeing and purging. On the other hand, if she never weighs herself, she just continues to feed her phobia about doing so. We have to strike the right balance-usually about once a week is enough.
I encourage the patient to discuss her disorder openly with friends and family. Removing some of the secrecy helps alleviate guilt and shame. It also lets other people take a more active role. Knowing that a family member is having trouble helps others to understand her behavior and offer emotional support.
By the end of this first stage we usually see a lot of improvement. The patient's mood is better, and the frequency of her bingeing drops. If not, though, I will consider adding medication or admitting her to the hospital.
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