Relapse in Eating Disorders

Understanding Relapse Dynamics in Anorexia and Bulimia

Relapse is a common occurrence after recovery from an eating disorder. A very simple definition of relapse is returning to a particular level of disordered eating after a period of full or partial remission from those behaviors. For example, a person with bulimia nervosa may be free of symptoms of binging and purging for a period of several months, and then begin to engage in binging and purging again.

Frequency of Relapse in Eating Disorders

Research on eating disorder relapse indicates that it seems to occur in at least one-third of those who achieve at least partial relief from eating disorder symptoms. Exact statistics are hard to achieve, as there are many ways that researchers define remission and relapse.

Defining Relapse and Remission in Eating Disorders

The definition of remission is important because a person can't relapse if there hasn't already been some level of recovery. Some define remission as a complete absence of eating disorder symptoms. Others might say there is at least partial remission if a person with anorexia nervosa is willing to maintain a normal body mass index (BMI) but still restricts her food intake on occasion, for example.

Does relapse mean a return to all previously-held eating disorder symptoms? Some portion of them? Once a definition of remission exists, the definition of relapse is open for debate.

While researchers differ on how to define relapse and remission, it is clear that relapse is a significant problem. The percentage of those who relapse has been reported to be as high as 60%.

Factors That Increase Risk of Relapse

There are several factors that contribute to higher risk of eating disorder relapse. One common factor is time: For both anorexia and bulimia, the greatest risk of relapse seems to be at about 6 to 7 months after achieving partial symptom remission. However, if a full year of remission can be reached without relapse, chances seem good that the individual will continue to do well. Risk for relapse for those with bulimia drops more quickly than for anorexia.

Other factors depend on the eating disorder in question.

For anorexia:

• Low desired weight
  If a person wishing to recover from anorexia has a goal weight that is low for his height, he will be more likely to relapse. Those who seek to maintain a body weight that will result in a below-normal body mass index (BMI) may be at much greater risk than those who seek to achieve a normal BMI.



• Long duration of disorder
  Anorexia responds best when addressed as early as possible. Treatment is less effective and relapse more likely if treatment is delayed.



• Presence of obsessive-compulsive disorder (OCD)
  OCD is common in eating disorders, as they fuel obsessions and compulsions.



• Excessive exercise
  The harder it is to maintain a normal weight, the easier it can be for anorexia to show up again. Too much exercise makes weight maintenance difficult.

For bulimia:

• Motivation
  In a rather odd twist, those with bulimia who are highly motivated are more likely to relapse soon after remission of symptoms. A possible explanation is that these people have unrealistic expectations about how their lives will change. If these expectations aren't met, it may be natural to return to familiar ways to self-soothe -- in this case, by engaging in disordered eating. As time passes, those with low motivation are more likely to relapse than those with high motivation.



• Level of remission
  With bulimia, those in partial remission seem more likely to relapse than those who achieve a complete remission of symptoms. This suggests that treatment for bulimia should pursue complete remission.

A few other factors appear in research on relapse in anorexia, but it's easy to imagine them encouraging relapse in bulimia as well:

• Depressive symptoms
  Depression in any form makes it harder to care for oneself.



• Stressful life events
  Problems such as broken relationships, abuse, or the loss of a job can trigger the original onset of an eating disorder. They can certainly make relapse more likely.



• Avoiding others to cope
  Relationships are very important to maintain emotional and mental health; being alone can be harmful.

Avoiding Relapse

For younger people with eating disorders, family therapy can help to maintain remission as new life skills grow and compensate for the lost disordered eating behaviors. But for those who have left their parents' homes, options are more scarce (and less well-researched).

A suggestion: Work hard up front to build a support network of friends (and family, if they're willing). Family therapy for younger people helps to change the structure of their daily lives, making it more likely that parents and siblings are allies rather than enemies. Having solid friendships accomplishes some of the same goals for those who are older.

What to Do About Relapse When it Does Occur

When relapse happens, many people react by telling themselves that they're failures. This view creates more stress and makes withdrawal and isolation more likely. Eating disorders feed on this dynamic.

If relapse happens to you, recognize what you've accomplished thus far. Relapse means that you've already known success; you've been in at least partial remission. The time that you were not engaged in disordered eating can't be taken away from you.

As with many struggles that have dynamics of addiction, relapse can simply be a step on the way to recovery. Viewing it as a temporary snag, rather than a prophecy of your future, can make all the difference.