FORM 4.1. Motivation Worksheet

FORM 4.2. Food Record

Planning Ahead:

Day: M T W Th F Sa Su Date: _

FORM 4.3. Information for Patients about Purging

People with bulimia nervosa typically purge after binges and/or meals to lower their anxiety, to feel less bloated, and to reduce the number of calories absorbed by their bodies. Vomiting is the typical means of purging, but laxative use also is relatively common. Although vomiting or laxatives may reduce your discomfort in the short term, you most likely feel intense shame, disgust, and anxiety soon after purging. Purging also keeps the eating disorder cycle going, making it even more likely that you'll restrict and binge again in the future. You probably are aware that vomiting and laxative use are dangerous. What you may not know is that purging is an ineffective way to lose weight. This handout will explain why purging is ineffective, the potential medical consequences of purging, and how to stop.

IS PURGING DANGEROUS?

There are many medical and psychological consequences of purging, some of which can be fatal. Even irregular vomiting or laxative use can cause dehydration, which in turn can cause organ damage. Both vomiting and laxative use can lead to electrolyte abnormalities, which are changes in your body's levels of potassium, sodium, and chloride. An electrolyte imbalance is very serious and can lead to fatal cardiac problems. Purging can increase your risk for dental erosion, periodontal disease, irritable bowel syndrome, other gastrointestinal distress, and osteoporosis. Do not be lured into a false sense of safety because laxatives are available over the counter. Frequent use of laxatives can cause intestinal damage, chronic constipation, and bowel tumors. Frequent vomiting can cause esophageal damage, which can be fatal.

why is vomiting ineffective?

Although most patients find this hard to believe at first, vomiting does not prevent your body from absorbing most of the calories ingested. Your body begins digesting food as soon as it is consumed, so calories are absorbed before you vomit. It also is impossible to vomit all food consumed; some of it will remain in your stomach afterward. Research has found that, on average, bulimic patients retain more than 53% of the calories from a binge. Often, they absorb much more than 50% of the calories consumed despite vomiting. You may believe that you have special "techniques" to increase the effectiveness of your vomiting, but these too are ineffective and dangerous. "Flushing," sustained vomiting, and use of "marker foods" do not work and may increase your risk for electrolyte imbalance and other medical consequences.

why are laxatives ineffective?

There are two basic kinds of laxatives: stimulant laxatives (Correctol, Senekot, Dulcolax, ex-lax) and bulking agents (Metamucil, Citrucel, FiberCon). Although they operate in different ways, neither decreases the amount of calories absorbed by the body. Laxatives only affect waste in your lower intestine, which is food that has already been fully digested by your body. Any weight lost after using laxatives is due to water loss, and this contributes to the serious risks of dehydration and electrolyte imbalance. Although you may feel less bloated after using laxatives, this sensation is temporary.

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HOW CAN I STOP?

• • You should stop vomiting and using laxatives immediately. It may feel difficult to stop purging abruptly, but it is possible and is the best way. Most people actually find it quite possible to stop vomiting and laxative use immediately. Stopping abruptly is preferred to gradual discontinuation of purging because the latter simply will prolong laxative withdrawal and anxiety symptoms.
• • If you try but are unable to stop "cold turkey," then gradually increase the time between your binge and purge. Start by waiting 10 minutes after bingeing/eating, do something to distract yourself while waiting, and then see if the urge to purge remains. On each successive occasion, increase the amount of time you wait to purge. This method will help you learn to tolerate the anxiety, and eventually you will see for yourself that you do not need to purge in order for the anxiety and bloated feeling to subside.
• • To make it easier to resist the urge to purge, remind yourself that this behavior is ineffective, read over the medical consequences of purging, throw out your supply of laxatives, and engage in a distracting activity after you eat (e.g., go for a walk, call a friend). The urge will pass—it always does!

WHAT CAN I EXPECT WHEN I STOP PURGING?

• • When you initially stop vomiting after binges, you likely will feel intensely anxious, worried about weight gain, physically full and bloated, and unable to concentrate on other activities. These sensations may last a few minutes, a few hours, or, infrequently, a couple of days. As with all physical and mental sensations, these will pass on their own—you do not need to purge to get rid of these feelings. Each time you successfully resist the urge to vomit, it will get easier.
• • When you stop relying on laxatives after binges, you will likely feel the same sensations as when you discontinue vomiting: anxiety, worry about weight gain, physically full and bloated, and difficulty concentrating on other activities. You also will likely feel constipated for several days and may gain a small amount of weight temporarily. If you have used laxatives frequently and for a long period of time, your lower intestine may be damaged and your body may be reliant on laxatives to produce a bowel movement. In these extreme cases, you may experience constipation for up to a few weeks. (See your medical doctor, who can discuss your options with you.)
• • To help ease constipation without the use of stimulant, bulking, or herbal laxatives: ^[1]

• [1] Eat regularly throughout the day, especially breakfast. • Drink more water. • Eat more whole grains, beans, fruits, and vegetables. • Engage in a moderate amount of exercise to stimulate your muscles.