Eating Disorder Relapse is Common - A Therapist's Perspective
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 who are unprepared for the possibility of a relapse, which is understandable. 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 does happen.
When relapse occurs and eating disorder symptoms worsen, there are a number of 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 way to do that is to work to prevent or minimize relapse.
Eating disorder relapse risk
Relapse rates for anorexia and bulimia have been reported to be between 36% and 35% respectively, according to one study (Keel et.al, 2005). Research shows that highest risk for relapse from anorexia nervosa is in the first 18 months after treatment (Berends et. al, 2016).
Unfortunately, even professionals can’t always predict who is vulnerable to relapse. Research has shown that — for adolescents — the less weight-restored they are when leaving treatment, the more likely that they will relapse (Hetman et. al, 2017). This happens because 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 for their body.
Some other reasons that might make an individual more susceptible to relapse include the following:
- 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
- Greater eating disorder thoughts and behaviors at time of discharge
- Losing weight quickly upon discharge
It is imperative to help patients maintain the gains made in their treatment. Loved ones can stay attuned to the following signs of relapse:
- Skipping meals or snacks or reducing the size of meals or snacks
- Eliminating individual food items or groups of foods
- Less openness to discussing recovery efforts
- An attitude of “I’m fine, don’t worry about me”
- Making excuses for not eating
- Changes in weight
- Eating alone or avoiding meal times with others, including not going out to eat
Loved ones can also be aware that certain times and experiences during an individual’s life may be more vulnerable to relapse. These include transitions such as:
- Starting/ending school or college
- Starting/ending a job
- Starting/ending a relationship
- 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; preventing relapse should be emphasized early in treatment.
No matter what your personal situation is and 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 the course of treatment and shared with loved ones who will help provide support and accountability. The plan should include specific factors that indicate the individual is struggling and the resulting actions that will be taken by the individual and by their loved ones. The more open the whole support system is about how the individual is doing, the better.
Eating disorder relapse defined
In order to understand relapse, we must discuss what relapse is, specifically. From the world of addictions treatment comes the helpful concepts of lapse, relapse and collapse.
- In recovery, a “lapse” is common. A lapse may be thought of as a slip, or as an isolated incident where an individual uses a behavior. In these cases, it is important to acknowledge the lapse and what contributed to it and essentially learn from the episode to handle the next situation differently. With the right attention, a lapse can be contained fairly quickly. Sometimes we tell our patients, “do the next right thing.”
- A “relapse,” on the other hand, is a longer episode or period of time of using symptoms in which the individual struggles to get back on track. This might 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 in order to manage worsened symptoms with more consistent support. So, depending upon the severity of the relapse from the eating disorder (is it a lapse, relapse, or collapse?) different interventions are required. This may include going back to inpatient or residential care.
Dealing with “slips” or “lapses”
Interestingly, research shows that how someone talks to themselves about a slip can make the difference in maintaining recovery or heading towards a relapse.
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 could guess that this kind of negative and self-critical talk could steer someone towards feeling badly about themselves and using behaviors again. We know that feeling shame about a behavior can lead someone to keep using that behavior, rather than preventing the behavior from happening again, although this may seem counter-intuitive.
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 really 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 staying focused on recovery.
In addition to managing their self-talk around a slip, patients should also refer to their relapse prevention plan in these instances and involve their family and treatment team as soon as possible to mobilize support. This approach should ensure the proper response so the individual can continue to move forward in their recovery more quickly.
In summary, loved ones should remember that they can help identify and contain a relapse. Loved ones, as well as the individual themselves, can: 1) Be prepared, 2) Plan ahead with a comprehensive relapse prevention plan, and 3) 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!
Angela Picot Derrick is a clinical psychologist and Senior Clinical Advisor at Eating Recovery Center of Chicago and Insight Behavioral Health Centers. Insight Behavioral Health Centers provides specialized treatment for mood and anxiety disorders at five Chicago, Illinois treatment centers and one center located north of Austin, Texas in Round Rock. Dr. Derrick has studied and treated eating and mood disorders for over 15 years and is honored to help her clients build hope, self-compassion and resilience as they work towards recovery.
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Berends, T., van Meifel, B., Nugteren, W., Deen, M., Danner, U.N., Hoek, H.W., and van Elburg, A. (2016). Rate, timing and predictors of relapse in patients with anorexia nervosa following a relapse prevention
program: a cohort study. BMC Psychiatry, 16(1): 316.
Carter, J.C., Mercer-Lynn, K.B., Norwood, S.J., Bewell-Weiss, C.V., Crosby, R.D., Woodside, D.B., and Olmsted, M.P. (2012.) A prospective study of predictors of relapse in anorexia nervosa: Implications for relapse prevention. Psychiatry Research, 200(2-3), 518-523.
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.
Keel, P.K., Dorer, D.J., Franko, D.L., Jackson, S.C., and Herzog, D.B. (2005). Post-remission predictors of relapse in women with eating disorders. American Journal of Psychiatry, 162(12), 2263-2268. [A nine-year follow-up study].
McFarlane, T., Olmsted, M.P., & Trottier, K. (2008). Timing and prediction of relapse in a transdiagnostic eating disorder sample. International Journal of Eating Disorders, 41(7), 587-593.