How To Recover From Bulimia

by | Mar 21, 2024 | Bulimia | 0 comments

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If you think you may have an eating disorder it is important to seek advice from your GP or health professional. The information in this blog post is intended for information purposes only and is not a substitute for personalised clinical advice. 

Recovering from bulimia isn’t easy. It’s probably one of the hardest things you’ll face in your life. Which is why thousands of people struggle in silence for years, if not decades.

But it is entirely possible to recover! If you throw yourself into the process, you can rebuild your relationship with food and live your life without food dominating every day.

This post will cover the steps you need to take to recover from bulimia. We’ll discuss what bulimia is, models of therapy, how to stop binging, meal planning, strategies to stop purging and building self-compassion.

What is bulimia?

In the UK, bulimia is diagnosed using the ICD-11. The criteria include frequent and recurrent episodes of binge eating (once a week or more). These episodes are followed by compensatory behaviours (e.g., self-induced vomiting, laxative misuse, excessive exercise).

Additionally, the criteria also highlight a persistent preoccupation with weight or body shape and marked distress about the pattern of eating.

The DSM-5 criteria for bulimia is widely used in America and has significant influence globally. The criteria are broadly the same as the ICD-11 although require the behaviours to be present for 3 months and that the behaviours are not better explained by anorexia.

It’s important to acknowledge that there may be significant overlap with other eating disorder diagnoses. Individuals may meet criteria for different eating disorders at various times, such as initially meeting the criteria for anorexia and later developing bulimia.

For this reason, it is important that your clinician takes a holistic view of your difficulties and tailors the treatment to meet your needs.  

Signs and symptoms

There are several signs and symptoms for bulimia. These are some common examples that you might notice in yourself or someone close to you:

  • You restrict what you eat in the day but lose control over your eating at night and binge on very large amounts of food.
  • You eat in secret or throw away packets before anyone else sees them.
  • You feel incredibly guilty after binging and make yourself sick, take laxatives, fast, or engage in excessive exercise to “make up” for it.
  • You are always “on a diet” or trying to lose weight.
  • You don’t like your body and perceive yourself as too big or fat.
  • You are often distracted by thinking about food and it makes it hard to concentrate on work or conversations with friends.
  • Meals out are very stressful, and you spent lots of time thinking about what you will eat.
  • Your mood has changed, and you feel very down and/or anxious.

Causes and risk factors

We don’t know exactly what causes bulimia. There are many contributing factors, and this will differ depending on the person. Some of the key themes are:

Social factors: western society places a huge emphasis on appearance and body size. We absorb these messages even from primary school ages. If people in our lives are dieting or concerned with weight, we learn to pay attention to weight and that it is important for us to be in control of it.

Biological: we know that people with a family history of eating disorders are more likely to develop an eating disorder themselves. Recent studies suggest that there may be a genetic component, although the precise details are not yet known.

Psychological: We know that people with bulimia are much more likely to have experienced traumatic life events than people without bulimia. Factors such as childhood abuse, poverty, domestic violence and more, might lead people to become vulnerable to develop an eating disorder. Sometimes binging can become a way to regulate emotions, even if it makes people feel worse in the long run.  

What maintains bulimia

Once people get stuck in a pattern of binging and purging it is incredibly difficult to escape the cycle. Below I’ve drawn out some common cycles that people get stuck in:

Do you notice any of these cycles in yourself? Which ones do you think are keeping you stuck? Looking at them all together we can understand why change is so hard, but it also gives us a roadmap for how to makes changes.

Motivation & readiness to change

Most people I work with are extremely keen to stop binging, but many people aren’t sure if they are ready to give up trying to lose weight. There are several stages of bulimia recovery, ranging from active bulimia to full recovery. And within this different levels of readiness to change.

For some, it is enough to think about the pros and cons and remind themselves of how strongly they want to escape the cycle of binging and purging.

For people who are hesitant, one common theme is not wanting to accept your body (or your weight) as it is. To move towards body acceptance, a good first step is to focus on all the things a healthy body will allow you to do.

Do you want to be strong to look after your children? Or healthy enough to travel the world? It might be as simple as wanting to stop feeling bloated or protect your teeth.

If the eating disorder is serving a function, for example helping you to regulate your emotions or cope with trauma, it makes sense that you would be scared to recover without resolving these issues.

Before undergoing trauma therapy, it is important to work on stability. This includes emotional stability and physical stability. Getting a regular pattern of eating and reducing binges and purges will give you the best foundation to work on overcoming trauma.

If you are not yet ready to recover from bulimia there are a number of tools you can use to build your motivation to change.

How to recover from bulimia

Therapy for bulimia

There are several types of therapy designed to help people recover from bulimia. In the UK the NICE guidelines provide evidence-based recommendations for treatment of eating disorders (and other health conditions). They recommend that people are offered either guided self-help (GSH) for bulimia or Cognitive Behavioural Therapy (CBT) for bulimia.

Guided self-help is based on the principles of CBT. People use an evidence-based self-help programme, such as Fairburn’s Overcoming Binge Eating, and supplement this with brief supportive sessions. Sessions are normally 20-30 minutes long, 4-10 sessions in total, including a staggered end to allow time for relapse prevention.

CBT for bulimia is 20 sessions long, spread over approximately 20 weeks. It’s recommended that sessions begin twice weekly to encourage positive change as soon as possible. CBT addresses myths about eating and purging, supports people with regular eating, works on body image problems, and emotional influences on binge-eating.

For children, NICE recommends that bulimia focused family therapy is offered.

When CBT doesn’t work

If you have tried CBT, and not found it helpful, the first step is to try and found out if you had ‘proper’ evidence-based CBT for bulimia. Unfortunately, it is not uncommon for people to believe they are having CBT for an eating disorder, when in fact they are receiving either a more generic version of CBT or a different therapy model entirely.

If you definitely did receive good CBT for bulimia, the next step is to consider alternative therapy models.

For people who CBT did not work for, consider schema therapy and compassion focussed therapy. Schema therapy focuses more on the childhood origins of current patterns of difficulties.

Compassion focussed therapy integrates some of the key CBT techniques but places emphasis on developing a kinder and more compassionate relationship with yourself.

DBT might also be very useful if you notice you are binging to cope with overwhelming emotions and this is causing you problems in multiples areas of your life (e.g., relationships, suicidal feelings, self-harm).

There are several self-help books aimed at introducing people to the different models of therapy and help you recover from bulimia.

Weight

Most people who are diagnosed with bulimia are either within the healthy weight range, or the overweight weight range.

Therapy for bulimia is unlikely to have a significant impact on your weight. Meaning it is unlikely to help you lose weight or cause any weight gain. This is because the first focus of therapy is to help you stabilise your eating pattern and significantly reduce binges.

Eating disorder specialists recommend that a BMI of 20 or above is needed to recover from bulimia. If you are dieting, or trying to keep your BMI below 20, it is very likely that you are trying to keep your body below it’s natural set-point. This is problematic because it triggers a biological drive to find food and eat, which makes you very vulnerable to binging.

Whilst you are in therapy, it’s recommended that you weigh yourself once a week (not more or less). Weighing yourself more frequently increases anxiety about weight and makes it difficult to interpret weight changes. Weight fluctuates for many reasons (e.g., hydration, hormones), so daily weighing is likely to become very confusing.

Avoiding weighing entirely is also likely to increase anxiety about weight. As you make changes to your eating you need enough information to fact-check any fears about what may be happening to your weight.  

Food

One of the most important steps in recovering from bulimia is establishing a pattern of regular eating.

Many people with bulimia are dieting or delay their eating for as long as possible in an atte-]0mpt to either lose weight or prevent binge eating. This pattern of eating means your blood sugar will drop and your body will start to drive you towards food.

In order to prevent this, aim to eat 3 meals a day and 2-3 snacks. Apart from overnight, make sure that you are not going for more than 3-4 hours without eating. For example:

8am Breakfast

10am Snack

1pm Lunch

3pm Snack

7pm dinner

9pm snack

Read these guidelines on eating in recovery and example meal plans to give you some ideas about what this might look like for you.

You might also be avoiding particular types of food. One of the most common food groups people avoid is carbohydrates. Unfortunately, this makes problems with binging much worse as you will be depleted of blood sugar very quickly. Work towards re-introducing all the main food groups.

Trigger foods

Gradually, you can also re-introduce other avoided foods (e.g., take-away, bread, crisps). If you find that some foods have historically been much more likely to trigger a binge, you might find that this is no longer the case now you are eating regularly.

If some foods still trigger a binge, it may be best to continue to avoid them temporarily, until you have worked on the other causes of binge eating. After a sustained period of time without binging, you can work on eating the most triggering foods once again.

As a side note, it is important to recognise that some foods are designed to make us over-consume. This is particularly true of ultra-processed foods. If you notice you over-consume highly processed foods, be compassionate to yourself. Food companies have spent thousands and thousands of pounds experimenting with recipes to make them highly palatable.

For this reason, you may choose to limit the amount of ultra-processed foods in your diet. On the other hand, it is best not to try and avoid these foods entirely as it may mean you are more likely to binge on them in the long run.  

Binging

There are two types of binges, subjective and objective. Objective binges are when a person consumes a very large amount of food in a short period of time (2 hours or less), with a sense of having totally lost control of their eating.

A subjective binge also happens in a short period of time, with a sense of having lost control, but the total volume of food eaten would not be considered unusually large given the circumstances.

Causes of binge eating

There are 4 main causes of binge eating.

Dieting (or under-eating) is the first main cause. We have hopefully already addressed via regular eating.

The second main cause is food rules (e.g., calorie counting, avoiding certain types of food, sticking to eating at certain times of day, avoiding restaurants). This makes people more vulnerable to eating because if you happen to break a rule (e.g., by eating 100 calories “too many”) it can trigger a “stuff it” mentality. “I’ve already broken the rule so I might as well binge and start again tomorrow”.

Start with one rule and try to phase it out or do the opposite. For example, if you normally totally avoid chocolate, try to reintroduce this at a pre-planned snack time.

The third cause of binging is disinhibition, or reduced self-control. A common cause of being disinhibited is drinking alcohol or taking drugs. Many people have the experience of overeating after drinking. Whilst you are recovering from bulimia, drinking is likely to make you much more vulnerable to bingeing.

Now is the time to reduce or cut out alcohol and/or drugs. Try asking yourself why you are drinking? Does it seem to make it easier to socialise? Or are you using it to relieve stress? Take this opportunity to address the root causes. For example, if you are chronically stressed perhaps, it is time to look for a new job, get more sleep, or spend more time outside.

The last causes of binge eating is emotional links. This is the largest and broadest category and includes a range of factors, from sadness, anxiety, trauma, stress and more.  The first step is to understand the triggers for your binge eating.

Self-monitoring

Self-monitoring is a tool used primarily in CBT for eating disorders. It involves keeping a diary of the food you have eaten, the time of day, where you ate it and the thoughts and feelings you are experiencing through-out the day.

You can use paper diaries, the notes section on your phone, or use a dedicated app. The purpose is to try and see patterns in your binging. Your notes should help you understand the triggers for binges: unde-reating, food rules, disinhibition or emotional links.

Urge surfing

If you have stopped dieting, you allow yourself to eat without rules, and have cut down on drinking and/or drugs but are still binging, you can try urge surging to prevent a binge.

People often feel an overwhelming urge to eat before a binge, this urge feels extremely difficult to resist. We know that this urge tends to peak and then gradually reduce over time, much like a wave. The purpose of urge surfing it to ride the peak of the urge until it becomes more manageable and passes.

You may wish to start by attempting to delay the binge if this feels more manageable. For example, you might start by delaying a binge by 10 minutes, and gradually build up to 30 minutes.

You can also use distraction to help you ride out the urge to binge. The distraction activity will be very specific to you. It could be anything from colouring, card games, knitting, calling a friend, or taking a shower.

The best activity is one that you find extremely engaging, and that you can have to hand. You might wish to choose 2 or 3 activities so that you have options if one is not possible in the moment.

Purging

Purging is a behaviour that is done to compensate for food eaten, usually during a binge. This could be vomiting, laxatives, diet pills, fasting, or excessive exercise. Sometimes people also misuse medications (e.g., insulin).

People typically purge to try and get rid of the calories eaten during a binge, to feel less “full”, and/or feel less guilty. Sometimes people purge outside of binges to try and reduce general calories eaten.

All these methods of purging carry significant risks to your health. Dehydration, electrolyte imbalances, damage to throat and teeth and, disruption to bowel function are all common.

What’s less well known is that purging is also relatively ineffective at removing calories eaten. Vomiting is thought to remove up to 50% of calories but is more likely to be about 30% for most people. Laxatives work on the lower part of the bowel and therefore remove almost no calories but do lead to a host of negative physical health consequences.

Because purging is most likely to happen after a binge, it is generally easiest to focus on regular eating and avoiding binges. But recovery is not a linear process and it’s likely that you will binge at points. Urge surfing can be used to wait out the urge to purge and protects you from the damage purging causes.

Exercise

Do you find you exercise only to burn calories? Do you exercise even when you are injured? Or feel extremely guilty if you don’t exercise? If you are trying to recover from bulimia, you may also need to address your relationship with exercise.

What exercise did you enjoy before you developed bulimia? If this was a long time ago, think back to how you enjoyed moving your body as a child. Do you enjoy being outside for example? Or joining in with a team sport?

Exercise can be very beneficial for mental wellbeing as well as physical health. It can also be enjoyable if you find the right activity. Check in with yourself whilst you are exercising:

  • Am I doing an exercise I really hate?
  • Do I feel like I have to keep exercising?
  • How is my body feeling, does it need to rest?
  • What is the primary reason I am exercising? Am I exercising to burn calories?

If you notice these red flags, step away from exercise and experiment with different ways of moving your body that you enjoy or can appreciate for the health benefits.

Body image

Most people with bulimia have significant difficulties with body image. You might find yourself constantly preoccupied with your body shape or weight. Or try to avoid any activities that might involve revealing your body (e.g., swimming, photos).

Take some time to think about if there are events in your life that may have made you more vulnerable to developing difficulties with your body. These might be direct links, such as societal pressures, bullying, messages from family or friends (intentional or unintentional).

They also might be indirect stressors, such as a period of illness that effected your body, isolation during COVID, or bereavement.

Knowing the origins of our body image helps us to take a new perspective and adopt a critical lens to decide which messages we want to hold on to, and which we chose to let go.

To repair our relationship with our body we can aim to return to having a neutral relationship with our body. What do you appreciate about your body? What does it allow you to do? How do you want to show your body respect and care?

Body checking and body avoidance can become vicious circles. The more we avoid or check our bodies (or both), generally the worse we feel. Gradually expose yourself to situations you would usually avoid and try to be conscious of when you are body checking and phase it out.

Managing emotions

Compassion-focussed therapy suggests that we all have three emotion systems. The threat system (alert for danger), drive system (motivates us to work or act), and soothing system (allows us to rest and feel calm).

Many people I work with find they spend most of their time in the threat and drive systems. The problem with this is that it is very exhausting to maintain. Our bodies need time in the soothing system to rest and recharge to prevent burnout and overwhelm.

The soothing system can be activated in a number of ways and people often test out a few ideas until they find the ones that fit well for them. Treating yourself with kindness is key, as when we criticise ourselves, we re-activate the threat system.

Some people find visualising a calming scene helpful. Others find a particular smell helps them to feel soothed. There are also several activities that might help you shift into your soothing system (e.g., gentle walks, bath, meditation, colouring, cuddling with a partner).

Links to your past & childhood.

For some people, recovering from bulimia will involve understanding how events in your past influence you in the present. If binging and purging is serving as a way for you to suppress your emotions or distract yourself from intrusive memories, a trauma focussed therapy might be appropriate.

If you are experiencing symptoms of PTSD, including flashbacks, nightmares, feeling on edge all the time, significant low mood, a therapy such as trauma-focussed CBT or EMDR might be appropriate. These therapies will help you process the memories of the traumatic events so that they have less impact on your daily life. They also help you to rediscover who you are and what is meaningful to you.

For other people, their past may have significantly impact them in other ways. For example, if you were abused or mistreated you might have developed beliefs or ‘modes’ to protect yourself, such as not trusting others or ignoring your needs. Or if you felt pressure to succeed you may find yourself constantly striving and unable to talk to yourself with kindness. Schema therapy can help you understand these links, what current patterns might be keeping you stuck, and explore how to develop a new and compassionate relationship with yourself.

Relapse prevention

Because recovering from bulimia is full of ups and downs, it is important to create a relapse prevention plan. Your plan should include possible triggers, warning signs, and strategies to put in place.

Triggers include any upcoming life events that you suspect might increase your vulnerability to dieting, binging, or purging. For example, a new job, moving house, transition to university, birth of a child.

Warning signs can be broken down into early and late signs. For example, an early warning sign might include, going on a diet and experiencing urges to binge. Late warning signs are more definite, such as resuming taking laxatives or binging in the evenings again.

For each warning sign I recommend coming up with an action you would like to do. For example, if you notice that you are starting to diet again, the action might be to remind yourself of the reasons you stopped and revisit your recovery meal plan for a few weeks until you feel confident to introduce more flexibility again.

Lastly, your plan should also include key people you can contact to get support. This might include your health professionals (GP, eating disorders service, psychologist) and key family and friends that you can trust will support you with recovery.

References

Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press.

Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: toward an integrative model of change. Journal of consulting and clinical psychology51(3), 390.

Simpson, E. S. S., & Smith, E. (2019). Schema Therapy for Eating Disorders. Taylor & Francis.

Targowski, K., Bank, S., Carter, O., Campbell, B. & Raykos, B. (2022). Break Free from ED. Perth, Western Australia: Centre for Clinical Interventions

Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V., & Russell, K. (2007). Cognitive behavioral therapy for eating disorders: A comprehensive treatment guide. Cambridge University Press.

Waller, G., Turner, H.M., Tatham, M., Mountford, V.A., & Wade, T.A. (2019). Brief Cognitive Behavioural Therapy for Non- Underweight Patients: CBT-T for Eating Disorders. Routledge.


If you are ready to recover from bulimia book a free consultation to see if we might be a good fit for you.

About

Welcome. I'm Dr Jenny Davis, a Clinical Psychologist with a special interest in eating disorders. I'm passionate about helping people recover and build a healthy relationship with food. 

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