TCPR:Dr. Bulik, I first learned about your work when I reviewed your book, Runaway Eating, which I rated as the best book for patients on eating disorders. I know that one of the reasons that you gave the book that title is that many patients don’t quite fit the conventional diagnostic categories of anorexia nervosa and bulimia nervosa.
Dr. Bulik: In most studies, 40-70% of patients with eating disorders receive the “eating disorder not otherwise specified” designation. So it’s true that our standard diagnoses don’t capture the majority of patients. “Runaway eating” implies a lack of control over eating behavior, which is the essence of the problem for many.
TCPR: What are some of these not-otherwise-specified eating disorders?
Dr. Bulik: These include patients with subthreshold symptoms that don’t quite meet criteria, patients who purge but do not binge, and patients with Binge Eating Disorder, which is a DSM-IV “research” diagnosis. An example of a subthreshold diagnosis is the patient with all the symptoms of anorexia nervosa except for amenorrhea. There are actually very little data to support the amenorrhea criterion. Patients may be quite anorectic without amenorrhea. Sometimes, patients will be on birth control pills, which cause an artificial period. Another example is patients who binge and purge only once a week rather than twice a week, as the diagnostic criteria stipulate. Patients who binge and purge once a week are just as impaired as those who do this twice a week. And since the disease is so chronic, patients may start out at once a week and then do it more frequently at times. It really doesn’t matter what the frequency is; as long as it causes distress and impairment, it requires an intervention.
TCPR: How would you suggest we work with such patients?
Dr. Bulik: We try to identify modifiable behavioral factors. Are there any behaviors they can change? The three most important things we can do are: 1. Encourage regular self-monitoring; 2. Reteach patients to have breakfast everyday; 3. Develop regular eating patterns.
TCPR: Let’s start with self-monitoring. What’s the purpose of it, and how should patients do it?
Dr. Bulik: Self-monitoring is useful because often patients come in with the feeling that their eating is chaotic, but when they actually take a look at it, they discover patterns. We give them a self-monitoring sheet and ask them to record everything they eat, what feelings they are having, what might be triggering their eating episodes. I ask patients to imagine they have a webcam on their shoulder recording every time they eat.
TCPR: Do patients tend to be pretty diligent with self-monitoring?
Dr. Bulik: They do pretty well. But I find that teenagers find self-monitoring sheets stigmatizing, and for this reason we have been using text messaging. We use a program that gives them automatic feedback. The text message is fed into a program that reads and evaluates their progress. It then sends them an immediate feedback message that tells them if they have met their goals, and how they did compared to yesterday. It helps motivate them to keep up the monitoring.
TCPR: You mentioned the importance of reteaching patients to have breakfast. Why is this so important?
Dr. Bulik: Our grandmothers used to say that breakfast is the most important meal, and it turns out that they were right, from both psychological and biological perspectives. Psychologically, when people skip breakfast, it sets them up for cognitions that can lead to disordered eating. For example, “I didn’t eat any breakfast so now I can eat more.” They might binge at that point, leading to the pattern of self-loathing, purging, and then more binging later in the day.
TCPR: And how is breakfast important biologically?
Dr. Bulik: Eating breakfast is what kick-starts our metabolism in the morning and this ultimately is what regulates our cycle of hunger and eating. So if patients can get in the habit of eating breakfast at a certain time, say 7:30 AM, they can expect to feel hungry again about 3 hours later, at 10:30 AM, and they can usually bridge that hunger with a small snack. Then they can eat a normal lunch.
TCPR: It sounds like this would tie into the third goal, that of developing regular eating habits throughout the day.
Dr. Bulik: Yes, and the goal here is to reteach patients to wait out intervals between eating and hunger. I often talk to patients about the natural rhythms of hunger and eating in terms of what a baby does. When a baby is hungry, she screams, she is fed, and she is full. Then there is a certain interval of time before she becomes hungry again, and she screams, and she is fed again. But patients with eating disorders often have no idea when they are hungry or full. This is particularly true for “grazers,” who eat almost constantly throughout the day. Their eating becomes uncoupled from the biological drive of hunger. We try to retrain patients to recognize the sensations of “I’m hungry” and “I’m full.”
TCPR: How does “emotional eating” play into your approach?
Dr. Bulik: Patients discover their emotional eating patterns in the course of self-monitoring. They tend to misperceive their satiety signals. Rather than responding to biological hunger signals, they begin to respond to emotional signals. For example, polishing off a bag of chips becomes an automatic response to boredom or emotional emptiness; eating chocolate might be a response to sadness; purging becomes a response to anger or agitation. These eating behaviors give a quick but transient fix. However, it’s important to remind patients that the best treatment for sadness is not chocolate, but rather, appropriate techniques for mood regulation. I teach patients to use food for hunger, and to use specific anxiety or mood regulation strategies for bad moods.
TCPR: What are some of the mood regulation strategies that you teach?
Dr. Bulik: The first thing I do is to make sure patients know the difference between minor mood blips and major depression, with the understanding that a major depressive episode requires either pharmacologic or therapeutic intervention. In terms of self-help techniques, I work with patients to develop their own strategies, and there’s a long list of them. I recommend readers look at a classic paper by Thayer and colleagues in which they polled 308 college students about what strategies they found most helpful for regulating their bad moods (Journal of Personality and Social Psychology 1994: 67:910-925). [Ed. note: this paper can be downloaded for free at http://www.csulb.edu/~psych/deptinfo/faculty/thayer/SelfRegulationofMood.pdf] But let me share some of the techniques that I’ve found particularly helpful. Music is a great immediate mood altering strategy. It provides several benefits, including energizing the body, releasing tension, lessening boredom, and relieving sadness. We’ve found that “oldies” are particularly helpful for patients, because they call up conditioned responses that are linked to pleasant memories [Ed. note: pp. 148-149 of Runaway Eating provides a great list of mood-altering songs categorized by specific emotional effect – they make a great emotional-boosting playlists for ipods!].
TCPR: And what are some of the other “greatest hit” strategies for patients?
Dr. Bulik: Exercise is one of the best ways to reduce tension and fatigue. In fact, in the Thayer study, exercise was the most effective method for regulating moods. Of course, in anorexia, excessive exercise is often one of the symptoms of the disorder, so you have to be careful about recommending this strategy in some patients. Another effective strategy is socializing. Patients sometimes underestimate the value of just picking up the phone and calling someone. Depressed patients may be reluctant to reach out because they feel they have nothing positive to contribute, but often that small amount of contact with the outside world can be mood elevating.
TCPR: These sound like great ideas. How do you help your patients to actually use these strategies when they have an impulse to binge or purge?
Dr. Bulik: I encourage them to do three things. First, I ask them to wait a minute. Even 60 seconds gives them an opportunity to consider what has triggered them and to think of alternative behaviors. Second, I encourage them to think specifically of what mood they are trying to change. I remind them that it’s not the food they want, it’s the change in mood. And finally, I have them use “panic cards” to remind themselves how to alter their moods constructively. These are simply 3 X 5 index cards that have some of the strategies that they have identified as being most useful for them. I ask my patients to keep these cards with them all the time, so they can quickly remind themselves of what they can do other than binging or purging. I’ve found this quite effective, because the urges are compelling and immediate, and these cards are quick reminders of some of the therapeutic work they’ve accomplished.