National Eating Disorders Association

Recovery from an eating disorder can take months, even years. Slips, backslides, and relapse tend to be the rule, rather than the exception. Re-learning normal eating habits and coping skills can take a long period of time and often requires lots of support from professionals, friends, and family. Moving forward is key, however slow it might be.

People struggling with an eating disorder have to address any immediate medical concerns caused by their disorder, work on reducing or eliminating eating disordered behaviors, address co-occurring issues like depression, anxiety, or trauma, and then develop a plan to prevent relapse. Some psychologists call recovery the process of creating a life worth living. Overcoming food and eating concerns during recovery is a central goal, but it’s far from the only task of recovery.

Psychologists have identified three broad areas of eating disorder recovery:

  • Physical recovery. This involves normalization of the physical effects of the eating disorder, including restoring weight to an appropriate level for the individual, normalizing electrolyte and hormone levels, resuming menstruation (if applicable), and other health issues caused by the eating disorder. Those with longer-term disorders may not be able to fully reverse all health consequences, but will be able to address other areas.
  • Behavioral recovery. This aspect of recovery means a cessation or dramatic reduction in food restriction, overexercise, purging, and/or binge eating.
  • Psychological recovery. Perhaps the hardest area of recovery to define, psychological recovery means addressing the cognitive and emotional aspects of the eating disorder, such as body image distress, perfectionism, and rules around food, eating, and weight. Those with co-occurring conditions such as mood and anxiety disorders may also need to manage those disorders to sustain lasting recovery.

Support System

An active support system often plays a key role in recovery. Parents can help encourage their children to stay in therapy, eat regular meals, and use new coping skills. Partners and friends can provide support during difficult meals and help build a life outside the eating disorder. For people with long-term eating disorders, normal social support systems have often waned, as friends and family often ‘burn out’ from providing care. So for some with eating disorders, recovery involves building a support system to help out when times get tough, as well as learning how to utilize it.

 

Body Image and Media

Although not everyone with an eating disorder experiences body image distortion and distress, many do. It’s not uncommon, especially in those who need to gain weight for recovery, for body image to get worse during early recovery. It also tends to be one of the last symptoms to disappear during recovery. Addressing these concerns isn’t vanity; distress about size and shape can have serious psychological and physical repercussions. Researchers have also found that body image concerns are one of the most common relapse triggers.

Recovery also involves challenging social norms about food, weight, and dieting. Our culture’s toxic messages around these issues means that eating disordered behaviors can be praised, and a clinical disorder disguised as just another diet. Some people have found it helpful to insulate themselves temporarily from these messages as they begin recovery. Later, when they are psychologically stronger, they can learn how to fight back against these social dictates. Many have found it helpful to think critically about media messages around the so-called ‘perfect body’ and ‘perfect diet’ and develop a more realistic, inclusive, and healthful definition for themselves.

 

Maintaining Recovery

Although everyone has the potential to recover fully, not everyone will. This is not the patient’s fault, but rather is caused by a complex range of issues, including lack of access to treatment at the right level and for a long-enough duration, imperfect treatments, sociocultural barriers (e.g., bias and discrimination against larger body sizes), and more. Even for those who don’t recover completely, treatment can often make dramatic improvements in level of symptoms and quality of life. 

Eating disorder researchers have yet to develop a set of criteria to accurately define what factors are necessary. Emerging results suggest that a full year without behaviors is a major indicator of recovery. Even if recovery is formally defined, each person’s recovery will look a little bit different. Some people may find the structure of a meal plan helps them stay well, while others prefer more flexibility around food. An active social life may be part of one person’s recovery while adequate time for solitude may be just as important for someone else. There’s no right or wrong way to do recovery.

 

Relapse

Recovery is a long and difficult process, and it’s common for people to return to eating disordered behaviors, especially during times of stress. Some common stressors include:

 

  • Going off to college
  • Moving to a new town or away from home
  • Starting a new job
  • Financial challenges
  • Infertility or getting pregnant
  • Birth of a child
  • Marriage or divorce
  • Death of a loved one
  • Diagnosis of a chronic disease
  • Menopause

 

It’s normal to be tempted to return to old behaviors during these times because you remember that they once made you feel better, at least temporarily. Hopefully, time in recovery has also shown you how much fuller life can be without an eating disorder.

Common warning signs of relapse

Just as all eating disorders are slightly different, so are all relapses. Still, many have a similar set of signs that can help identify potential problems:

  • Avoiding meals and events involving food
  • Making efforts to eat alone
  • A return to obsessing about food and weight
  • Overwhelming feelings of shame and guilt after eating
  • Concealing information from loved ones and your treatment team
  • Resuming repeatedly checking appearance in the mirror and weighing outside of treatment
  • Justifying small slips and lapses, saying that it’s no big deal or it’s not that bad
  • Becoming irritable when the subject of food or eating disorders is brought up
  • An increase in stress with no way to manage it
  • Increasing anxiety, perfectionism, and depression
  • Sleep disturbances
  • Isolation from friends and loved ones

The best way to deal with relapse is to accept the possibility that it might happen, soon or in the distant future, and make a plan to help manage it. 

  • Identify your triggers. Based on what you’ve learned in recovery, identify the types of situations where you think you might be most likely to struggle. Write down as many as you can realistically think of.
  • Identify warning signs. What are signs that recovery is continuing to go well for you? What about when you might need more support? Lastly, what are the signs that you are in full-blown relapse? Note psychological, behavioral, and social signs, such as avoiding meals, not sleeping well, increasing perfectionism, irritability, and breaking plans with friends.
  • Identify support people. Find several people, including a therapist, dietitian, psychiatrist, or other professional, whom you can turn to when you’re stressed or having concerns about emerging eating disordered behavior. If appropriate, encourage them to talk to you about any concerns they see as well.

References:

Bachner-Melman, R., Zohar, A. H., & Ebstein, R. P. (2006). An examination of cognitive versus behavioral components of recovery from anorexia nervosa. The Journal of nervous and mental disease, 194(9), 697-703.

Bardone-Cone, A. M., Harney, M. B., Maldonado, C. R., Lawson, M. A., Robinson, D. P., Smith, R., & Tosh, A. (2010). Defining recovery from an eating disorder: Conceptualization, validation, and examination of psychosocial functioning and psychiatric comorbidity. Behaviour research and therapy, 48(3), 194-202.

Bardone‐Cone, A. M., Sturm, K., Lawson, M. A., Robinson, D. P., & Smith, R. (2010). Perfectionism across stages of recovery from eating disorders. International Journal of Eating Disorders, 43(2), 139-148.

Björk, T., Clinton, D., & Norring, C. (2011). The impact of different outcome measures on estimates of remission in a 3‐year follow‐up of eating disorders. European Eating Disorders Review, 19(1), 2-11.

Eddy, K. T., Tabri, N., Thomas, J. J., Murray, H. B., Keshaviah, A., Hastings, E., ... & Franko, D. L. (2016). Recovery From Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up. The Journal of clinical psychiatry.

Keel, P. K., Dorer, D. J., Franko, D. L., Jackson, S. C., & Herzog, D. B. (2005). Postremission predictors of relapse in women with eating disorders. American Journal of Psychiatry, 162(12), 2263-2268.

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.