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December 21, 2023

5 Signs Your Patient May Be at Risk of an Eating Disorder Relapse

5 Signs Your Patient May Be at Risk of an Eating Disorder Relapse

It’s arduous work to unlearn the negative self-beliefs and destructive patterns of an eating disorder. Even with robust, specialized treatment, a caring support system, and a firm personal commitment to recovery, many individuals will encounter lapses or relapse as they recover.

Eating disorders are highly recurrent by nature, meaning that relapse can be a normal part of the recovery process. Longitudinal cohort and treatment follow-up studies estimate that 20% to 50% of those with eating disorders will relapse. The risk of relapse is exceptionally high in individuals who are recovering from anorexia nervosa, especially those within the first year of their discharge from treatment.

Given the significant rates of relapse and their associated burdens—cognitive, emotional, social, financial, and physical/medical—effective relapse monitoring and assessment are vital. As a provider, you are an invaluable ally in helping your patient keep the path of recovery. By being prepared to intervene at the warning signs of a relapse, you can set your patient up for a strong and resilient recovery.

What is an Eating Disorder Relapse?

An eating disorder relapse is classified as any return to eating disorder behaviors and symptoms. Unlike a “lapse,” which may be considered a “slip” or an isolated incident, relapses are longer episodes or a period of using disordered symptoms. We often tell our clients that “A slip doesn’t have to be a slide” and “Just do the next right thing,” meaning that they have the power to contain any lapses by staying self-aware and acting in alignment with their recovery goals.

If an individual relapses in their recovery, it is crucial they get back on track as soon as possible. This may mean increased support and skill-building, such as extra sessions with members of their treatment team. It may also result in the need for additional structure, such as stepping into a higher level of care.

Research tells us that the first year after completing treatment is the most vulnerable time for clients, with a continued risk lasting for up to two years. Timing and specific risks will vary. According to a recent eating disorder meta-analysis, common predictors of relapse include:

  • Length of illness. The longer an individual has suffered from an eating disorder, the more likely they are to relapse in recovery.
  • Severity of illness. More severe psychopathology predicts a higher likelihood of eating disorder relapse.
  • Eating behaviors. Consuming an overall diet of low energy density or a limited variety of food predicts a higher likelihood of relapse.
  • Psychiatric comorbidities. Exposure to traumatic events, obsessive and compulsive symptoms, depressive symptoms, suicidality, and postpartum depression are linked to higher rates of relapse.
  • Motivation to change. Higher motivation for treatment and recovery is associated with a lower likelihood of relapse. Additionally, applying the knowledge and skills from treatment, such as challenging distorted thinking, undoubtedly aids in reducing the risk of relapse.
  • Where treatment occurred. If an individual was treated in a hospital or by a general clinic, that patient is more likely to relapse. Individuals treated in eating disorder specialty centers are less likely to relapse during recovery.
  • Self-defeating beliefs. Having low levels of self-acceptance, low self-compassion, and unrealistic expectations about recovery can make relapse more likely.
  • Lack of community. Those in recovery who lack strong social supports may find themselves at a higher rate of relapse. A stable connection to others offers much-needed validation and accountability in recovery.
  • Stressful life events. Big life events can trigger a relapse. These events can include loss, trauma, relationship difficulties, holidays, beginning a new job, starting or returning to school, moving, getting married, weight loss unrelated to an eating disorder (e.g., medication, illness, increase in activity, etc.) undergoing surgery, transitioning from treatment to the real world, and more.

Warning Signs of an Eating Disorder Relapse

The warning signs of relapse can overlap with the warning signs for the onset of an eating disorder. Eating disorders are notorious manipulators that thrive in secrecy and isolation. Your patient’s eating disorder may keep them from explicitly asking for help or lead them to deny that there is a problem. They may not even realize they are struggling again, despite evidence of relapse. As such, it is very important to know what symptoms can be an indicator of an eating disorder relapse.

You may be able to observe relapse warning signs in your patients. However, to truly understand each patient’s unique eating disorder and recovery experience, you must incorporate screening questions into your patient sessions. Outer appearance rarely tells the full story—even more so in the case of eating disorders, which are, at their core, complex brain-based illnesses. You must go beyond visible signs to assess whether a patient’s relationship with food and their body warrants further attention and care.

Consider the following five categories of eating disorder relapse presentations. Remember, the earlier a relapse is detected, the better your patient’s outcome.

Behavioral Signs

  • Reported changes in eating patterns or reverting to disordered eating behaviors (e.g., skipping meals, restricting, following food “rules,” binge eating)
  • Disclosure of a new workout plan
  • Indications that patient has developed repetitive or obsessive body checking behaviors (e.g., repeated weighing, pinching skin, looking in mirrors often)
  • Evidence of purging behaviors (e.g., excessive exercise)
  • Pronounced secrecy around food and eating (particularly as the patient struggling may know others are aware of their eating disorder history)
  • Reports of neglecting self-care or upholding basic needs
  • Looking back at the eating disorder with fondness
  • Changes in clothing style, such as wearing baggier or less-revealing clothes

Psychological Signs

  • Increase in negative/distorted body image or self-criticism
  • Patient’s thoughts continue to turn back to weight and food
  • Heightened sensitivity to comments or concerns about body shape or weight, eating, or exercise habits
  • Emerging or worsening changes in mood, such as depression or anxiety symptoms or signs of euphoria
  • Continual denial of hunger
  • Increased moodiness or irritability
  • Comments indicating low self-esteem (e.g., feeling worthless, feelings of shame, guilt, or self-loathing)
  • Rigid ‘black and white’ thinking (viewing everything as either ‘good’ or ‘bad’)
  • Perfectionistic thinking returns or becomes stronger
  • A reported increasing need to be in control over many things
  • Expressions of guilt or feeling “out of control” after eating

Social Signs

  • Expressed withdrawal or disinterest in social activities or events involving food
  • Isolating oneself from friends, family, and other relationships
  • Avoidance of activities previously enjoyed
  • Disclosures of dishonesty with friends and family
  • Reported work or school-related performance issues
  • Interpersonal conflicts or criticism related to food or recovery

Physical Signs

  • Observed or reported sudden weight gain or loss
  • For younger patients, a lack of expected growth
  • Reported menstrual irregularity
  • Changes in vital signs or bloodwork
  • Disclosure of or observed dizziness, fainting, weakness, fatigue, or insomnia
  • Signs of frequent vomiting (e.g., swollen cheeks or jawline, calluses on knuckles, damage to teeth)
  • Reported frequent stomach upset or digestive issues
  • Observed or reported markers of poor nutrition, such as excessive bruising, thinning hair, dry skin, brittle nails, sensitivity to the cold

Relapse-Specific Signs: Changes in Motivation to Recover

  • Reported deviations from post-treatment plan
  • Disclose of or observed disconnect from recovery goals (e.g., shifting from a set meal plan, showing difficulty accepting support from others)
  • A demonstrated pattern of missing or rescheduling appointments
  • Holding unrealistic recovery expectations (e.g., refusal to discuss a relapse prevention plan, viewing lapses in recovery as personal “failures”)

Why Referrals for Care Can’t Wait

Eating disorders are complex and dynamic; it’s common throughout recovery to occasionally have periodic returns of eating disorder thoughts or behaviors.

Your screening efforts and timely care referrals matter. From a medical standpoint, your ability to spot relapse red flags in your patients and jump into action can be lifesaving. A multidisciplinary team can best address eating disorders, and your referral for care means setting your patient up for lasting healing.

In identifying the signs of a relapse, you also have the opportunity to help mediate your patient’s resiliency and shape their response to relapsing. It’s essential to recognize how distressing eating disorder relapse can be for patients. During a relapse, thoughts may return to the negative beliefs they held at the beginning of their recovery journey. In addition to the fear that recovery may not be possible for them, a patient may experience:

  • The fear of “starting over” with treatment
  • The fear of losing progress or being a “failure”
  • The fear of relapsing further or that “things are getting bad again”
  • The fear of judgment from providers/loved ones
  • The fear of disappointing others

It makes sense to fear losing the hard work of recovery. Encourage your patient to be kind to themselves. Recovery isn’t perfect, and it doesn’t need to be. A lapse or relapse doesn’t mean recovery is out of reach; patients with prior treatment—and, in turn, prior knowledge, skills, and resources—are generally more equipped to face the challenges of recovery. People recover from eating disorders and overcome relapses every day. Your patient can find their way back to recovery.

Is your patient currently experiencing relapse in recovery? The Emily Program is here to help reignite the hope of a life free from disordered eating. We offer warm care for individuals at all stages of recovery and those grappling with relapse. Call us at 1-888-364-5977 or complete our online referral form.



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