ecovery is a lifelong process for those who have struggled or are struggling with an eating disorder. For some people, treatment may be enough to create lasting changes, but the reality is, struggling with recovery and even relapse is not an uncommon experience.
One study found that relapse occurred in 36% of people with anorexia nervosa and 35% of people with bulimia nervosa. (1) While these rates may seem discouraging, it can be helpful to reframe relapses as a temporary bump in the road, as opposed to an indication that treatment didn’t work or that your loved one has failed.
Viewing a relapse as a problem that informs us of where we may have vulnerabilities, is a way to use this struggle as an opportunity to gain a deeper understanding of ourselves and our needs. It is therefore important to develop an ability to reflect on behaviors that may indicate that a person is struggling and at risk of an eating disorder relapse, so you can support your friend or family member and get them the help they need.
What is an Eating Disorder Relapse?
Unlike relapses for a substance use disorder, which tend to be clearly marked by returning to substance use, eating disorder relapses are a bit harder to define. This is especially true given that there are many different types of eating disorders, each with its own symptoms and patterns of disordered eating. But generally, an eating disorder relapse is characterized by a return to disordered eating behaviors after a period of remission or recovery.
One study had a more detailed definition of anorexia nervosa relapse, characterizing it by experiencing weight loss, an increased score on the eating disorder evaluation (EDE), medical issues, and disordered eating behaviors. (2) Certainly “weighing” a relapse based on actual body weight is short-sighted and misses the reality of the underlying pain, suffering and struggles of individuals who experience eating disorders. It is also vital that clinicians not evaluate suffering based on a person’s weight, and/or rely on weight solely as an indication of recovery. A person can be deeply engaged in compromising behavior, and struggling significantly, while not having any significant weight changes at all.
The one guiding principle of relapse, whether the person has binge eating disorder, exercise addiction, orthorexia nervosa, bulimia nervosa, or any form of anorexia nervosa, is that your loved one has returned to their previous unhealthy patterns related to eating, restricting, binging, or exercising. Beyond these outward behaviors, the person is struggling internally, which may or may not be apparent to an outsider.
Warning Signs of a Relapse
Knowing the warning signs of an eating disorder relapse can help you to play an integral role in your loved one’s recovery process.
Some possible warning signs of a relapse include:
- Regularly checking their weight
- Skipping meals or occasions involving food
- Regularly eating alone
- Engaging in excessive exercise
- Seeming ashamed or guilty after eating
- Isolating themself from friends and family
- Repeatedly checking their appearance in the mirror
- Seeming irritable whenever food is discussed
- Appearing sad or depressed
- Wearing loose-fitting clothing
- Hiding information from you or other members of their support system
- Appearing stressed or anxious
- Sleeping way more or less than they usually do
- Avoiding social activities
If you are worried that your loved one is at risk of relapsing, you can help enact their relapse prevention plan. Encourage your loved one to seek extra support, whether that be additional therapy sessions or attending more frequent support group meetings. In the event of an actual relapse, you can empower your friend or family member to re-enter an eating disorder treatment program.
Risk Factors for Eating Disorder Relapse
Re-learning healthy eating habits doesn’t happen overnight—it’s an ongoing process that often consists of slips or relapses. The risk of relapse is particularly evident during times of stress or major life transitions. Further, one study found that the highest risk period for eating disorder relapse was between four and nine months after completing treatment. (3) Knowing this can help you prepare for slips or relapses by having a set plan of action in place.
Common risk factors for eating disorder relapse include:
- Moving to a new city or state
- Starting a new job
- Going through a divorce
- Becoming a new parent
- Experiencing infertility
- Going through menopause
- Receiving a serious medical diagnosis
- Experiencing the death of a loved one
- Going away to college
- Experiencing financial issues
Additionally, one study found that poor body image and psychosocial functioning increased the risk of relapse for people in recovery from anorexia nervosa and bulimia nervosa. (1) Psychosocial functioning refers to a person’s ability to engage in healthy social relationships and perform the activities of daily living. So, if you notice your loved one seems to be struggling with their day-to-day tasks or relationships, this could be a sign they need additional care or support.
Another study revealed that a decrease in motivation during and after treatment were both predictors of eating disorder relapse. (3)
How to Support Someone in Eating Disorder Recovery
It’s natural to want to help your family member or friend during their recovery from an eating disorder, but it can also be intimidating or scary. If you’re feeling overwhelmed or are unsure where to start, here are some things you can do to support them while also taking care of yourself:
- Research their eating disorder
- Keep a copy of their relapse prevention plan on-hand (and/or ask them if they would be willing to share this prior to discharge from treatment programs they may be involved in)
- Recognize your loved one’s triggers and let them know that you want to be supportive, while asking them for their feedback on how you can provide this support
- Be flexible and allow for a recovery plan to change or evolve
- Approach their recovery from a compassionate and nonjudgmental place
- Focus on your loved one as a whole person; they are not their eating disorder
- Remind them of how far they’ve come
- Express how proud you are of their progress
- Attend support groups with them if they request you to
- Change the way you talk about body image and weight being sure to be educated about the impact of weight stigma and the destructive influence of diet culture
- Model a body-positive attitude
- Provide your loved one with a safe space to vent
- Validate their feelings when they confide in you when appropriate, and encourage them to speak with professionals if their eating disorder symptoms appear to be causing them to be unaware of how their behavior is playing out with food
- Ask your friend or family member what they need from you
- Acknowledge slips or backslides when appropriate, by encouraging your loved one to stay gentle with themselves and be in search of learning what they can about themselves if they do struggle.
- Create a self-care plan for yourself and make sure you tend to your needs. Although we all want to help our loved one, we must first “provide oxygen to ourselves”
What to Do if a Loved One Relapses
The most important thing to remember is that relapsing does not mean your loved one has failed or that eating disorder treatment didn’t work. It simply means that they need some extra support right now to deepen their healing process.
Relapse is a common part of the recovery process and should be treated as such. Someone in eating disorder recovery who has relapsed is likely feeling extremely ashamed and guilty about it—the worst thing you can do is add to that shame and guilt by blaming them or catastrophizing the experience. Instead, you should express your support for your loved one during this vulnerable time and make space for their feelings and experiences. This act of “making space” for feelings and experiences is hugely beneficial to the patient and to your relationship with your loved one.
Encourage self-compassion and remind them how much progress they’ve made. At Within Health, we love to use the language of “compassionate curiosity” to think about how we want to reflect on our thoughts, feelings and behaviors. Compassion is tied to depth of understanding, while judgement is generally tied to having a lack of awareness or knowledge. Research shows that self-compassion reduces eating disorder symptoms and body image issues and is associated with greater positive body image.4 You can help foster self-compassion in your loved one by encouraging them to: (4)
- View their relapse or slip in a nonjudgmental, compassionate way
- Understand that emotional pain is a shared human experience
- Treat themself with the same empathy and kindness they would someone they care about
- Recognize their negative emotions as valid and even necessary
- Support the idea that even when we struggle, choosing gentleness as the next step is ALWAYS the right choice.
Lastly, if your friend or family member is struggling to return to their recovery plan, you may want to encourage them to re-enter an eating disorder treatment program where they will receive the structured support they need to get back on track.
- 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. The American journal of psychiatry, 162(12), 2263–2268.
- Khalsa, S.S., Portnoff, L.C., McCurdy-McKinnon, D. et al. What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa. J Eat Disord 5, 20 (2017).
- Carter, J. C., Mercer-Lynn, K. B., Norwood, S. J., Bewell-Weiss, C. V., Crosby, R. D., Woodside, D. B., & 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.
- Turk, F. & Waller, G. (2020). Is self-compassion relevant to the pathology and treatment of eating and body image concerns? A systematic review and meta-analysis. Clinical Psychology Review 79, e1-e19.