Eating Disorder Relapse is Common

By Angela Picot Derrick, clinical psychologist and Senior Clinical Advisor at Eating Recovery Center | Pathlight Mood & Anxiety Center in Chicago.

Many families are familiar with the frustrations of loving someone with an eating disorder. A loved one agrees to go to treatment, does the difficult work of therapy and comes out in a better place… but before long, the eating disorder creeps in, little by little, avoiding detection until a relapse is fully underway.

This heart-wrenching situation is particularly concerning because the more momentum an eating disorder picks up, and the longer it goes undetected, the more difficult it can be to confront and treat.

We see many individuals picking up their loved ones from treatment, unprepared for the possibility of a relapse. Their intense hope for complete and lasting recovery outweighs the fact that some individuals do relapse. They are then even more surprised, upset and confused when relapse happens.

When relapse occurs and eating disorder symptoms worsen, there are several consequences: cognitive, emotional, social, financial and physical/medical. An individual’s hope and motivation to recover may lessen; denial that recovery is possible can set in. For these reasons, it is crucial to know how to help loved ones maintain gains made in recovery. One important strategy is to prevent or minimize relapse.

Eating disorder symptoms & warning signs

Dieting is the number one preceptor to an eating disorder, but it does not cause it. That said, when someone in recovery begins demonstrating diet behaviors, it is cause for concern. Watch this short video to learn more.

Eating disorder relapse rates

Research indicates that more than a third of all patients treated for anorexia or bulimia relapse within the first few years of completing treatment. The highest risk for relapse from anorexia nervosa occurs in the first 18 months after treatment, with 35% falling back into eating disordered behaviors.^[1]

While the onset of bulimia usually occurs during adolescence or early adulthood, it tends to persist for several years, either chronically or intermittently. Treatment does help most people with bulimia achieve long-lasting recovery, but relapse remains a significant concern, with rates of up to 41% of former patients resuming bulimic behaviors within 2 years.^[2]

Eating disorder relapse defined

To understand relapse, we must specifically discuss what relapse is. From the world of addiction treatment comes the helpful concepts of lapse, relapse and collapse.

• In recovery, a “lapse” is common. A lapse may be considered a slip, or an isolated incident where an individual engages in a behavior. In these cases, it is important to acknowledge the lapse, understand what contributed to it and learn from the episode to handle the next situation differently. With the right attention, a lapse can be contained quickly. We sometimes tell our patients, “Do the next right thing.”
• A “relapse,” on the other hand, is a longer episode or period of using symptoms in which the individual struggles to get back on track. This may happen during a time of stress or transition and could be met with increasing support and structure for the individual, such as an extra meeting with the dietitian, therapist, or family therapist, or access to supported dinners for a week.
• Finally, a “collapse” indicates that the individual has not been able to contain the relapse and may need a higher level of care to manage worsened symptoms with more consistent support. Depending on the severity of the incident (is it a lapse, relapse, or collapse?) different interventions are required. This may include going back to inpatient or residential care.

Signs that someone may be susceptible to relapse

Unfortunately, even professionals cannot always predict who is vulnerable to relapse. Research has shown that among adolescents, the less weight-restored they are when leaving treatment, the more likely they will relapse.^[3] Leaving treatment before the body has had an opportunity to stabilize weight means that even slight dips in weight can leave someone in an unhealthy weight range.

Additional factors that may make an individual more susceptible to relapse include:

• Poor body image
• A strong link between body image and self-esteem, or feeling that one’s self-worth is tied to appearance
• Poor social relationships
• Slower response to treatment interventions
• Low motivation to recover during and after treatment
• Intensified eating disorder thoughts and behaviors at time of discharge
• Rapid weight loss upon discharge

Eating disorder relapse warning signs

It is imperative to help patients maintain the gains made in treatment, reinforcing the critical importance of family involvement. Emotion-Focused Family Therapy (EFFT) empowers caregivers to better support their loved ones through continued involvement, education and support. The modality also helps families develop strategies for protecting progress after treatment, such as staying attuned to the following warning signs of relapse:

• Skipping meals or snacks or reducing the size of meals or snacks
• Eliminating individual food items or groups of foods
• Demonstrating less openness to discussing recovery efforts
• Displaying an attitude of “I’m fine, don’t worry about me”
• Making excuses for not eating
• Exhibiting weight changes
• Eating alone or avoiding mealtimes with others, including not going out to eat

Common eating disorder relapse triggers

Loved ones can remain aware that certain periods during an individual’s life may make them more vulnerable to relapse. Otherwise, life events can trigger stress and anxiety that lead to eating disordered behaviors as a coping mechanism. It is important to pay close attention to how loved ones manage during these times and be ready to support them.

These include transitions such as:

• Starting/ending school or college
• Starting/ending a job
• Starting/ending a relationship
• Moving
• Becoming pregnant
• Having a baby/becoming a parent
• Weight changes associated with physical health, aging or pregnancy
• Physical injury or lessened mobility
• Traumatic events

Eating disorder relapse prevention

One way to help prevent relapse is to follow the old Boy Scout motto: be prepared. Many eating disorder treatment programs offer weekly relapse prevention groups, understanding that this should be emphasized early in treatment. One recovery advocate notes that reaching out to others is one strategy she uses to avoid relapse.

No matter what your personal situation is or what your loved one is going through, you must acknowledge the risk and prepare for the possibility of relapse.

When an individual leaves treatment, experts recommend that they have a detailed, personalized relapse plan based upon their own unique circumstances. This plan should be created throughout treatment and shared with loved ones to provide support and accountability. The plan should include specific factors that help indicate if and when the individual is struggling, and the resulting actions that will be taken. The more open the entire support system is about how the individual is doing, the better.

Dealing with “slips” or “lapses”

Words matter, especially when it comes to self-talk. Research shows that how someone talks to themselves about a slip can make the difference in maintaining recovery or heading towards a relapse.

Self-talk: What not to say and why

After a slip or a lapse, someone might say:

“Well, there I go again. I’ve really blown it. See, I knew I hadn’t changed. I guess all that treatment was for nothing. My parents are going to be really disappointed when they hear about this one.”

We can infer that this kind of negative and self-critical talk could steer someone towards feeling bad about themselves and using disordered behaviors again. While it may seem counter intuitive, we know that shame about a behavior can lead someone to keep using that behavior, rather than preventing the behavior from happening again.

Self-talk: What to say instead and why

A more helpful and recovery-focused way to respond to a slip is this:

“I am disappointed that I used a behavior when I felt angry. I wish I had been better prepared for that situation. I do see what I need to do differently next time. Slips are bound to happen in recovery, but overall, I am doing much better than before treatment and that feels hopeful.”

This way of talking to oneself is a skill that builds self-compassion. With greater self-compassion, individuals learn to navigate a healthier relationship with themselves that is kind, forgiving and ultimately helpful to staying aligned to their goals, including a continued focus on recovery.

In addition to managing self-talk around a slip, patients should also refer to their relapse prevention plan in these instances and involve their support networks and treatment team as soon as possible. This approach helps ensure the appropriate response and assists the individual in moving forward in their recovery.

In summary, loved ones should remember that they can help identify and contain a relapse. 1) Be prepared, 2) Plan ahead with a comprehensive relapse prevention plan3) Identify action steps and self-compassionate self-talk in advance. And please, maintain hope.

Always remember this when it comes to eating disorder relapse: A full recovery from an eating disorder is possible!

Sources

^[1] Berends, T., van Meijel, B., Nugteren, W. et al. Rate, timing and predictors of relapse in patients with anorexia nervosa following a relapse prevention program: a cohort study. BMC Psychiatry 16, 316 (2016). https://doi.org/10.1186/s12888-016-1019-y

^[2] BMC Psychiatry. 2019; 19: 134. Published online 2019 May 6. doi: 10.1186/s12888-019-2112-9

^[3] Hetman, I., Klomek, A.B., Goldzweig, G., Hadas, A., Horwitz, M., & Fennig, S. (2017.) Percentage from target weight (PFTW) predicts re-hospitalization in adolescent anorexia nervosa. Israel Journal of Psychiatry, 54 (3), 28-34.