Bulimia and binge-eating disorder: a therapist's manual

1. The programme at a glance

Indication. Bulimia or binge-eating disorder in an adult, in outpatient care, at a weight that does not require specific physical management, with a medical assessment done.

Reference model. Cognitive behavioural therapy for eating disorders (Fairburn, 2008; Waller et al., 2007): early restoration of regular eating, withdrawal of compensatory behaviours (everything the person does to "undo" what they have eaten: section 5) and dietary rules, then underlying work on the overvaluation of shape and weight in self-esteem (section 6).

Format. Twenty sessions over twenty weeks in ordinary practice; this manual describes twelve, tightened up, and indicates the points for extension, that is, the parts to develop when more sessions are available (section 15). Sessions of 50 minutes, two a week at the start, and not negotiable, then weekly: the close spacing of the first three weeks is aimed at early change, that is, a fall in the binges from the very first weeks, which predicts the outcome (section 12). Three booster sessions, at one month, three months and six months (section 28).

Mechanism targeted. Interrupting the restriction-binge-compensation cycle at its starting point, that is, by restoring regular eating, and not by strengthening control (section 4). Then withdrawing what maintains the system: the rules, the food avoidances, the body checking, and the outsized place that weight occupies in self-esteem.

Session	Subject	Deliverable of the session
1	Assess and engage	Safety checked, model explained
2	The record and the weighing	Real-time record, weekly weighing installed
3	Regular eating	Three meals, two snacks, times written down
4	Replacing the binges	Two alternative behaviours tried
5	Stopping the compensations	Compensation dropped after a planned meal
6	Mid-point review	Obstacles identified, plan revised
7	Dietary rules	Three rules deliberately broken
8	Avoided foods	List in four groups, written reintroduction schedule
9	Body image	The self-esteem diagram, drawn
10	Checking and avoidance	Checking behaviours listed, two withdrawn, one avoidance faced
11	Events and emotions	One written alternative per emotion
12	Review, relapse, maintenance	Written plan, measures repeated

Two tools recur throughout the programme. The record is the notebook in which the person notes each intake at the very moment it takes place (section 30). The self-esteem diagram is a circle that they divide into slices according to what counts in the way they judge themselves, and which makes the place of weight visible (section 32).

What the person takes away. Seven printable worksheets, listed in section 39: my record, my times, my rules, my foods, my diagram, the corner for those close, my plan for what comes next.

What sets this programme apart from the other manuals on this site. Three things. An early behavioural intervention that comes before any cognitive work. An explicit refusal of the goal that a large proportion of patients come looking for — weight loss. And an underlying target that is not eating behaviour but the place of weight in self-esteem.

2. Before you start

The four preliminary decisions

Is the weight low, or has the loss been rapid? If so, this manual does not apply: the presentation calls for a specialist service. Section 3.

Is there a physical risk? Look for frequent vomiting, use of laxatives or diuretics, faints, palpitations and, in a person with diabetes, a deliberate reduction in insulin doses to control weight (section 10). The medical assessment comes before the programme.

Is there a suicide risk or self-harming behaviour? These are frequent in this population and must be asked about explicitly (section 9).

And what exactly is it? Bulimia, binge-eating disorder or another presentation: section 3 helps to decide.

What this programme does not treat

It does not treat anorexia nervosa or low-weight presentations, which require supervised refeeding and close physical monitoring.

It does not treat physical emergencies. Electrolyte disturbances (abnormalities of potassium and the other minerals in the blood, which vomiting and laxatives can cause), faints, chest pain and haematemesis (vomiting blood) are emergencies.

It does not conduct weight loss. Section 34.

And it does not on its own treat an eating disorder associated with major instability, that is, physical instability (electrolyte disturbances, faints, abnormal vital signs). This is first a matter for the doctor, then for an integrated service, where the two problems are managed together.

How to use it

Read the whole before the first session, in particular sections 4, 10, 29, 32 and 34: restriction, medical safety, regular eating, body image, and the question of weight.

Each session is described according to the same framework: the aim, the steps, what you say, common errors, and the criterion for moving on, that is, what must have been achieved before moving on to the next session.

Three warnings specific to this reason for consulting.

The shame is immense and it organises the secrecy. Many patients have never told anyone what they do in the evening. The first session decides what will be said afterwards.

The patient often comes for the wrong reason. They come to stop putting on weight, or to lose weight. That request is not to be refused: it is to be worked with, and section 34 says how.

And the first weeks are counter-intuitive. You ask someone who is afraid of eating to eat more, and more regularly. Without an explanation, nobody does it.

3. Four presentations not to be confused

1. Bulimia

What you observe. Recurrent binges — a clearly large quantity of food, within a limited time, with a feeling of loss of control — followed by compensatory behaviours: vomiting, laxatives, diuretics, fasting, excessive exercise. And a self-esteem very largely determined by shape and weight.

What that implies. It is the programme described here.

2. Binge-eating disorder

What you observe. The same binges, without regular compensatory behaviours. They go with rapid eating, to the point of discomfort, without hunger, alone out of shame, and with a feeling of self-disgust afterwards.

What differs. The weight is more often high, the restriction is less systematic between binges but it almost always exists in the form of repeated diets, and the request for weight loss is almost constant.

What that implies. The same programme, with two differences: session 5 changes content (section 36), and the question of weight takes up more room (section 34).

3. Anorexia nervosa

What you observe. A restriction leading to a low weight, an intense fear of putting on weight, and an altered perception of the body. Binges and vomiting may also be present.

What settles it. The weight and how it is changing: a low weight, or rapid weight loss (section 2).

What that implies. A different service: close physical monitoring, supervised refeeding, often a team. This manual does not apply there, and applying it would be dangerous. Anorexia nervosa: a therapist's manual describes this treatment, from shared medical follow-up and the right level of care to regular eating resumed with the doctor and the dietitian.

4. The other presentations

What you observe. Forms that do not meet all the criteria: less frequent binges, compensations without binges, night-time episodes (with the adaptation indicated in section 8).

What that implies. These forms are frequent, they are not milder, and the programme generally applies.

The three other things to have ruled out

A medical cause. A digestive condition, an endocrine disorder, or the effects of a treatment.

Overeating without loss of control. Eating a lot is not a binge; what distinguishes a binge from simply eating too much is the feeling of being unable to stop.

And the manipulation of a treatment. In a person with diabetes, deliberately reducing insulin to control weight is a compensation, it is serious, and it is never reported spontaneously.

The three sorting questions

"Do you sometimes eat an amount that others would find abnormal, without being able to stop?" The question that isolates the binge.

"What do you do afterwards?" The question that isolates the compensations, and each one has to be named, because patients spontaneously report only the vomiting.

"Does your weight or your shape decide how you judge yourself?" The question that isolates the underlying mechanism, and that predicts relapse.

4. Restriction: the engine of the cycle

What has to be understood above all

Binges are not a problem of willpower. They are the predictable consequence of an irregular deprivation. An organism that does not receive enough, or not regularly enough, produces a pressure towards food that ends by winning — and that wins all the more violently the stricter the restriction has been.

That is what the work on semi-starvation in volunteers without any disorder has long shown: obsessive preoccupation with food, loss of control over eating, unstable mood, social withdrawal. These features appear in people who had no disorder beforehand, and they fade with refeeding, sometimes slowly (Keys et al., 1950).

What that changes

You do not strengthen the control. Every attempt to eat less in order to avoid binges produces binges.

You eat more regularly, and often more, from the third session onwards.

And you explain it before asking for it. Without that explanation, the instruction looks absurd and nobody follows it.

The forms of restriction

Skipping a meal. No breakfast, no lunch, and an evening that ends badly.

Delay. Waiting as late as possible before the first meal.

Quantity. Meals too light to last.

Quality. The avoidance of whole categories of food.

Rules. "Nothing after 8 pm." "No starch in the evening." "Nothing until I have done my workout."

And anticipatory compensation. Eating less because there is an evening out ahead, which guarantees the binge.

The full cycle

The cycle starts with restriction. Physiological hunger and preoccupation with food increase until the breaking point: that is the binge. Then come the distress and the sense of failure, then the compensation, and the decision to "do better tomorrow", which takes the form of a stricter restriction. The cycle then starts again, more tightly.

Two further entry points also lead into it: an event or an emotion that directly triggers the binge, and a broken rule that produces the thought "it is ruined, I may as well carry on".

That is the diagram you draw in session 1.

5. The compensatory behaviours

What they are

Everything done to undo what has been eaten, or to control weight in a way that falls outside ordinary eating.

Self-induced vomiting.

Laxatives.

Diuretics.

Fasting and skipping meals after a binge.

Excessive or compulsive physical exercise, often not counted as a compensation by the patient.

The manipulation of a treatment, in particular insulin.

And appetite suppressants or slimming products, including those sold without prescription.

What has to be known, and said

Vomiting does not remove everything that has been eaten, far from it. That piece of information alone brings the frequency down in some patients, because, once it is known, the benefit-cost ratio of vomiting collapses.

Laxatives do not act on the absorption of calories. They act further down, once the food has been absorbed. The weight loss they produce is a loss of water, it is regained immediately, and they maintain a constipation that makes them indispensable.

Diuretics have no effect on fat mass and carry real risks.

And the compensations keep the binges going. Knowing that one will be able to compensate removes the inhibition: that is what allows the binge to happen, and that is why withdrawing them is part of the treatment of the binges, rather than a mere consequence of it.

How they are withdrawn

After regular eating has been installed, never before: as long as the restriction continues, the binges continue (section 4).

Starting with the compensations that follow a normal meal, not those that follow a binge: they are easier to withdraw, and withdrawing them shows the person that they can keep a meal down (session 5).

Handling the stopping of laxatives with the doctor, because stopping produces a transient constipation and water retention, which are the leading cause of going back to laxatives.

And by announcing the water retention. The weight may go back up for a few days when vomiting or laxatives are stopped; you do, however, need to hold on for three weeks before judging the trend. Not announcing this rise guarantees that the person gives up.

---