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October 1, 2019

How Primary Care Providers Can Support Sustained ED Recovery and Recognize Signs of Relapse

When a client has a history of an eating disorder, it’s essential to be aware of the signs of eating disorder relapse. If a client states they are struggling with relapse, a provider has one job: to get them to an eating disorder assessment. Healthcare providers shouldn’t feel like they have to make the patient feel better on their own, and they certainly shouldn’t tell the client they should wait to see what happens.

If a client communicates concerns about eating, they’ve probably had concerns for quite some time. This isn’t something people often share in the first month that it is happening. Once noticed, the provider needs to treat the eating disorder the same way that they would treat any other disease–connecting their client with the best person to treat the illness.

A common mistake made in primary care offices is a medical provider saying, “Maybe you’ll snap out of it, come back to see me in a month and we can see what happened.” Two or three things are likely to occur in this scenario. The client may hear that what is happening to them is not that serious, perhaps thinking, “My doctor doesn’t think it’s a big deal, so maybe it’s not.” Another outcome may be that the person will get worse over the next month. And if the eating disorder gets worse, it becomes increasingly less likely that they will seek treatment. So, telling someone to wait should be avoided at all costs.

A second problem is when providers don’t fully understand fully that not eating enough is far more dangerous for most people than eating too much. If I’m seeing a 15-year-old in my office who is either 30 pounds underweight or 30 pounds overweight, clearly that 30 pounds underweight is much more dangerous and life-threatening for that client in particular. Many times, the underweight client will instead be validated for their great weight control and the overweight client will be shamed. Neither of these responses are helpful and both increase the likelihood that someone who needs treatment will not get it. 

The most important thing a primary care physician can do for someone in recovery is to see them regularly, have an ongoing conversation with them, understand that they will not get better overnight, and that client more frequently than they would see the average client. Plan to see them every month, plan to follow their progress, plan to get vital signs, check weights, and have conversations about what is going on in their life. Stress can be a predictor of relapse. Many people who have received eating disorder treatment will be seeing a therapist and/or nutritionist.  The primary care provider should, if possible, have an open dialogue with other members of the care team, they can coordinate care. 

A huge warning sign for a primary care provider would be if a patient came in and said they were no longer seeing anyone from their treatment team.. Eating disorders are best addressed by a multidisciplinary care team, so that is a huge warning sign. Clearly, changes in vital signs, bloodwork, or other significant changes in health are other warning signs that are of great concern. 

It is also important to emphasize is that a primary care provider is in a unique position. Typically, the primary care provider is the only member of the treatment team that knew the client before their eating disorder began, so they may have a relationship that is unique and not illness-based. This perspective could be beneficial throughout the recovery process if the primary care provider can recognize disordered thoughts and behaviors in contrast to an individual’s baseline. 

If there are signs of relapse, it is imperative that a client receives an eating disorder assessment. The experts who assess for eating disorders and level of care are fantastic, so the patient and provider should feel comfortable knowing that their client is in good hands.  If a client does not think they are struggling but the provider sees signs of relapse, that is a very hard situation. It’s challenging to tell someone who doesn’t think that they are ill that they are. This is part of what makes eating disorder treatment so difficult and we wouldn’t expect all providers to be experts in this. 

The primary care provider can be in a great position to help facilitate getting help with the relapse, though.  This can be  done by pointing to specific medical concerns and saying, “This is dangerous.” This can include heart rate changes, weight changes, lethargy, and other things. Being able to say “these are the facts I’m seeing” rather than having a debate is important. I also recommend saying, “Go back and get an assessment, if you’re right and you aren’t ill, that’s what the assessor will say. I’m not asking you to start treatment again, I’m just asking you to go back, get an assessment, and prove me wrong. If you are right and that’s what the assessment says, I’ll back off.” From there, the patient will often complete an assessment, and a new plan can be put into place.  In short, the unique perspective of the primary care provider can be a critical key in sustaining ED recovery. 


Mark Warren

Mark Warren, MD

Mark Warren is the chief medical officer of The Emily Program. He is also one of the original founders of the Cleveland Center for Eating Disorders, which became The Emily Program – Cleveland in 2014. A Cleveland native, he is a graduate of the Johns Hopkins University Medical School and completed his residency at Harvard Medical School. He served as Chairman of the Department of Psychiatry at Mt. Sinai Hospital and Medical Director of University Hospital Health System’s Laurelwood Hospital. A past vice-chair for clinical affairs at the Case School of Medicine Department of Psychiatry, he continues on the Clinical Faculty of the Medical School, teaching in both the Departments of Psychiatry and Pediatrics. He is currently a faculty member and former chair of the Board of Governors at the Gestalt Institute of Cleveland. Dr. Warren is a Distinguished Fellow of the American Psychiatric Association, a two-time recipient of the Exemplary Psychiatrist Award of the National Alliance for the Mentally Ill, and a winner of the Woodruff Award. He leads the Males and Eating Disorders special interest group for the Academy of Eating Disorders.

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