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02 October 2012

Our researchers wrote the first self-care manual for bulimia to use cognitive behaviour therapy techniques. Now translated into six languages, and adapted as an online therapy, it is recommended as the first step in treating the disorder.

Research led by Professors Ulrike Schmidt & Janet Treasure

Our researchers wrote the first self-care manual for bulimia to use cognitive behaviour therapy techniques. Now translated into six languages, and adapted as an online therapy, it is recommended as the first step in treating the disorder.

© King’s College London Image Library
© King’s College London Image Library

An estimated eight per cent of women experience bulimia at some time in their lives. Our researchers pioneered the development of ‘guided self-care’ to help break the characteristic cycle of bingeing and purging.

Professors Ulrike Schmidt and Janet Treasure – who lead our eating disorders research team – wrote Getting Better Bit(e) by Bit(e) in 1993, the first ever self-care manual for bulimia that used cognitive behaviour therapy (CBT) techniques. They then showed, in a number of trials, that if people worked through the manual with support from a therapist, it was as effective as individual or group CBT – and more cost-effective.

Getting Better Bit(e) by Bit(e) has so far been translated into German, Italian, Spanish, French, Dutch and Japanese, and was originally produced in response to an increased number of women seeking help for bulimia in the eating disorders specialist outpatient clinics at the South London and Maudsley NHS Foundation Trust (SLaM).

‘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.’

Bit(e) by Bit(e) was full of ‘real-life stories’ and the accompanying Clinician’s Guide was developed to help therapists give customised support to women who were working their way through the manual.

Since then, our researchers have evaluated new ways of providing 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.

Professor Schmidt and colleagues first evaluated Overcoming Bulimia, computer software developed at the University of Glasgow, and then worked with a digital organisation to translate the CD-ROM into a web-based programme.

The research team continues to refine the online therapy and explore alternative ways of providing support and guidance from a therapist. 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 an email therapist,’ says Professor Schmidt. 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 2004 NICE guideline on eating disorders recommended self-help treatment for both anorexia nervosa and bulimia nervosa. A 2012 review by the Royal College of Psychiatrists showed that 67 per cent of UK specialist eating disorders services use self-care interventions for the treatment of bulimia.

Guided self-care is also recommended as the first step in the treatment of bulimia in Germany and the USA.



  • Schmidt & Treasure. Getting Better Bit(e) by Bit(e), a survival kit for sufferers of bulimia nervosa and binge eating disorders, 1993; Psychology Press
  • Treasure J. et al. First step in managing bulimia nervosa: controlled trial of therapeutic manual. BMJ, 1994 March 12; 308 (6930): 686-9
  • Schmidt U. et al. Randomised controlled trial of CD-ROM based cognitive behavioural self-care for bulimia nervosa. British Journal of Psychiatry, 2008 December; 193(6):493-500
  • Pretorius N. et al. Cognitive-behavioural therapy for adolescents with bulimic symptomatology: the acceptability and effectiveness of internet-based delivery. Behaviour Research and Therapy, 2009 September; 47 (9): 729-36
  • Eating Disorders: Core interventions in the treatment and managements of anorexia nervosa, bulimia nervosa and related eating disorders, National Institute for Health and Clinical Excellence guideline, 2004
  • Overcoming Bulimia,
  • Hibbs, R., Rhind, C., Leppanen, J. & Treasure, J. Interventions for caregivers of someone with an eating disorder: A meta-analysis. Int J Eat Disord.e pub, 2014
  • Raenker, S., Hibbs, R., Goddard, E., Naumann, U., Arcelus, J., Ayton, A., Bamford, B., Boughton, N., Connan, F., Goss, K., Lazlo, B., Morgan, J., Moore, K., Robertson, D., Schreiber-Kounine, C., Sharma, S., Whitehead, L., Beecham, J., Schmidt, U. & Treasure, J. Caregiving and coping in carers of people withanorexia nervosa admitted for intensive hospital care. Int J Eat Disord, 2013; 46: 346-54
  • Goddard E, Macdonald P, Sepulveda AR, Naumann U, Landau S, Schmidt U, et al. Cognitive interpersonal maintenance model of eating disorders: intervention for carers. The British Journal of Psychiatry : the Journal of Mental Science, 2011; 199(3): 225-31

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