How to prevent relapses in eating disorders?
The therapeutic process for eating disorders (EDs) is long and complex. This is due, among other factors, to the frequency of relapses, which is approximately 30% of cases.
We would first need to clarify what we mean by relapse, since there isn't even a clear clinical consensus on the matter. It would be helpful to differentiate between two concepts:
- Clinical fluctuations during treatment: To achieve good therapeutic progress, it is essential to first develop an awareness of the problem and a motivation for change, characteristics that are not usually present at the beginning. It is also important to keep in mind that these are not absolute categories, but rather are reached through a gradual and irregular process. Therefore, it is common for progress and setbacks to alternate throughout therapy. In reality, this is part of the "path to recovery" and would not be considered a relapse.
- Relapse : clinical worsening after a period of partial or total improvement of a few weeks. Thus, the following behaviors reappear in a sustained manner: behaviors aimed at weight loss (for example: restrictive dieting, compensatory activity such as physical exercise or self-induced vomiting), preoccupation with weight or physical appearance (with frequent and excessive checking of weight, or avoidance of activities that involve exposure of body image), or organic complications that had resolved (loss of menstruation).
Relapses occur mostly in the first year after recovery, declining considerably from the second year onwards.
Identifying a relapse in anorexia and bulimia
Like the onset of the disorder, relapse is usually a gradual process. Several distinct stages can be identified:
- Stage 1 (initial): no objective symptoms of eating disorder, there is only an increase in concerns about weight and food, but the person still knows how to handle it.
- Stage 2: worries cause greater anxiety and, to alleviate it, the person again has controlling behaviors that from the outside would not yet be noticeable (for example: choosing a food from a menu only because they consider it less caloric, or avoiding a sweet treat even though they really want it).
- Stage 3: The behaviors become more frequent. This is when there is an impact on weight.
- Stage 4: presence of evident clinical symptoms related to the eating disorder (marked weight loss, organic consequences, increased distress).
And also, as with the onset of the disorder, each person follows their own path to developing it. In this process, there are two very important characteristics to consider:
- Risk factors : These are situations that trigger an increase in the worries characteristic of eating disorders. They are not always directly related to appearance; sometimes they are simply other stressful factors (for example, exams, a family member's illness) that lead the person to try to manage anxiety by controlling their body.
- Warning signs : these would be "mini symptoms", slight changes in intake (for example: always avoiding snacks), physical activity (never taking the elevator), organic (weight loss), cognitive (disproportionate fear of a specific food) or social (more arguments with parents about the origin of the food)
What are the main warning signs of eating disorders?
The importance of knowing the risk factors and warning signs lies in the fact that a person often experiences the same symptoms with each episode. In other words, if, for example, the onset occurred after eating less due to stress during an exam period, each academic assessment could pose a risk of another episode.
By definition, the initial stages are only detectable by the person with the eating disorder, so if they are unaware of the problem, they are difficult to perceive. More advanced stages can be observed by those around them.
How to manage a relapse in anorexia or bulimia
Although there are several ways to manage these situations, we consider it interesting to explain Berends' relapse prevention program (2010).
This is based in turn on Van Ommen's theoretical model, which proposes defining three main categories when establishing a preventive intervention:
- Taking responsibility : who makes the decisions (person being cared for, family, clinical team).
- The provision of a structure : where the changes take place (home, outpatient consultations, partial or total admission)
- The normalization of eating patterns and physical activity.
The person with an eating disorder and their family must understand that these three points must be kept in mind throughout treatment and follow-up. Depending on the stage of the disorder, the first two points change (generally, greater severity requires greater responsibility and supervision from the clinical team).
To personalize this program, the aforementioned risk factors and warning signs must be included.
Subsequently, a series of intervention measures are agreed upon jointly with the person receiving care and their family. It is preferable to base these measures on the positive characteristics of the person with the eating disorder (for example, sociability and perseverance) and on previous interventions that have been successful (such as using reading as a distraction). It should also be specified whether these measures will be implemented by the person receiving care or by another support person.
All of this takes considerable time, as the goal is to define different situations in detail and decide who will do what at any given time. Once established, a therapeutic contract is signed between the person receiving care, their family, and the clinical team.
To give a practical example: a person with anorexia or bulimia might identify exam periods as one of their risk factors. For them, the warning sign would be the thought that, since they don't have free time, it's better to skip their afternoon snack to make the most of the afternoon. Their plan might stipulate that if this thought arises, they will "force" themselves to eat at least a piece of fruit, but without mentioning their concern to anyone.
If anxiety worsens, the previously agreed-upon support person (for example, her sister) can suggest relaxing activities (for example, helping with studies or taking her to do something enjoyable). If both anxiety and restrictive behavior increase, impacting her weight, the person with the eating disorder requests an earlier appointment with their clinical team for evaluation.
Regarding the timing for planning and agreeing on this intervention, there is a growing consensus to propose it as soon as partial clinical improvement is achieved, as it appears to have a positive therapeutic effect. In any case, whenever it is performed, it seems to significantly improve the prognosis.
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