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 condi-tioned responses that are linked to pleasant memories [Ed. note: pp.148-149 of Runaway Eating provides a great list of mood-altering songscategorized by specific emotional effect – they make a great emotional-boosting play-lists for i-pods!].

TCPR: And what are some of the other “greatest hit” strategiesfor patients?

Dr. Bulik: Exercise is one of the best ways to reduce tension andfatigue. In fact, in the Thayer study, exercise was the most effectivemethod for regulating moods. Of course, in anorexia, excessiveexercise 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.