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Professors Ulrike Schmidt and Janet Treasure from King's College London's Institute of Psychiatry wrote the first ever self-care manual for bulimia that used cognitive behaviour therapy techniques. The manual has now been adapted to be delivered online.

An estimated eight per cent of women(1) will experience bulimia at some time in their lives. For thousands of them, 'guided self-care' can make a real difference and help break the characteristic cycle of bingeing and purging.

Researchers at King's College London's Institute of Psychiatry, were pioneers in developing this sort of treatment, recommended by the National Institute for Health and Clinical Excellence (NICE) and now easily accessible online.

Back in 1993, Professors Ulrike Schmidt and Janet Treasure – who lead the eating disorders research team at King's Institute of Psychiatry – wrote Getting Better Bit(e) by Bit(e), the first ever self-care manual for bulimia that used cognitive behaviour therapy (CBT) techniques. They went on to show in a number of trials that if people worked through the manual with the support of a therapist, it was as good as individual or group CBT – and more cost-effective.

Since then, they and colleagues in the eating disorders research team at King's Institute of Psychiatry have been evaluating new ways of giving people with bulimia quick access to guided self-care via computer programmes and the internet – and have demonstrated that these modes of delivery work well, particularly for web-literate younger women.

Getting Better Bit(e) by Bit(e) – which has been translated into six languages – was originally produced in response to an increased number of women seeking help for bulimia in the eating disorders specialist outpatient clinics run by the South London and Maudsley NHS Foundation Trust (SLaM) where Professor Schmidt also works as a consultant psychiatrist.

'This was the time when bulimia was beginning to get into public consciousness, when women were overcoming their sense of shame and seeking help,' she says. 'We were completely swamped with patients.' (The number of women visiting their GPs to talk about their eating disorder increased dramatically when reports of Princess Diana's battle with bulimia hit the headlines in 1992).

Bit(e) by Bit(e) was full of 'real life stories' and the accompanying Clinician's Guide (published in 1997) was developed to help a therapist give customised support to women who were working their way through the manual.

The eating disorders research team next started looking at delivering self-care using new technologies: Professor Schmidt and colleagues first evaluated Overcoming Bulimia, computer software developed by Professor Chris Williams at University of Glasgow, and then worked with Media Innovation in Leeds to translate the CD Rom into a web-based programme.

Research continues on honing the online therapy (and exploring alternative ways of providing support and guidance from a therapist), but in the meantime, Overcoming Bulimia online is now offered routinely and immediately to women referred to the SLaM outpatient clinic at their first appointment. 'We send those who choose this option home with a log in and email therapist,' says Professor Schmidt, who is a professor of eating disorders. The alternative is to join the waiting list for one-to-one or group CBT.

Professor Schmidt says self-care online may be particularly appropriate for women who have bulimia, many of whom may be ashamed of their eating disorder. 'Women with bulimia often don't ask for help, which means their condition can get worse and be harder to treat,' she says. 'Making self-help treatment available online means patients don't have to come regularly to a hospital or outpatient clinic. This is also a more efficient use of scarce NHS resources.'

The NICE guideline on eating disorders, including recommended treatment for both anorexia nervosa and bulimia nervosa, was published in 2004 (and is due for review in January 2014). Guided self-care is also recommended as the first step in the treatment of bulimia in the German guidelines on the Diagnosis and Treatment of Eating Disorders, published by the Association of the Scientific Medical Societies in Germany (AWMF) in 2011.

Both Overcoming Bulimia and Getting Better Bit(e) by Bit(e) are recommended by the Royal College of Psychiatrists in information produced for the public about eating disorders.

In 2012, the Royal College of Psychiatrists produced new 'quality standards' for different types of eating disorders services. Based on existing guidelines – NICE guidance, for example – the soon-to-be published standards for outpatient clinics recommend guided self-care for bulimia.

The Royal College of Psychiatrist's Centre for Quality Improvement is now promoting the standards to specialist eating disorders services across the country through a Quality Network for Eating Disorders. The aim is to make sure people who experience eating disorders are offered a uniformly high standard of care.


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