Women who have required treatment in hospital are more vulnerable to relapse than those who have been less ill and have been treated as out-patients. During the recovery period the woman should have continuing contact with her dietitian and the therapist at varying intervals. In addition, the woman should know that she can contact her dietitian or her therapist at any time.
A second group of patients who may need continuing help are those who have apparently recovered from anorexia nervosa, but are worried that a relapse is about to occur. It is important for these women to know that they can quickly obtain help from a therapist whom they trust and with whom they feel comfortable.
Some women are unable to achieve the desired body weight even after treatment. Their body weight stabilizes at a weight well below the normal range. These women cannot be considered ‘cured’ as they continue to be preoccupied with thoughts about weight and food, continue a rigid lifestyle to maintain their restricting behavior, and tend to avoid challenges to this way of life. In other words their eating disorder continues to interfere with their daily living. They are particularly likely to have a relapse during which their weight decreases and they become ill.
Other women, whose weight has returned to the normal range, but who continue to be preoccupied, to some extent, with thoughts of weight and food, may relapse if they have a life stress or some other challenge, such as an impending examination, a change of job, illness, marriage, or divorce. Some women with anorexia nervosa replace their abnormal eating behavior with an exercise disorder or alcohol dependence, during which they may relapse into a further episode of anorexia nervosa.
As well as being able to contact their therapist easily and quickly, in many cases the relapse can be prevented if the woman follows these guidelines. She is aware that it is preferable for her to allow her body weight to increase a little after she has achieved the target recommended during refeeding. This permits her body to correct the ratio of lean (mostly muscle) tissue to fat tissue so that its composition is normal. Tries to avoid any further weight loss for any reason. For example, if she has a period of illness when she loses weight she should try to regain that weight (even if it is only a kilogram) as quickly as possible. Avoids situations which keep her thinking about food, her body shape, or weight. For this reason she should avoid working in a job involving food preparation or serving, for example, working as a waitress or in a restaurant or take-away food shop. Avoids changing her routine too much. Avoids long holidays or trips overseas. In an unfamiliar environment, with the loss of routine, frequent new experiences, and different foods, she may feel that she has lost control and reverts to restricting her food intake or binge-eating and using dangerous compensatory methods of weight control.
Kara, a 22-year-old ex-patient of ours, returned from overseas and entered the Eating Disorders Unit for refeeding. Her story is an example of what may happen if a woman who is recovering from anorexia nervosa goes overseas too early. She wrote: "Dorothy there's no question about it, it has to be done. It's like I can't see beyond the actual obsession. I can't do anything to distract myself. I wouldn't know what to do till I'd done it. I just hurry and get it over—done with as fast as possible so I can relax. It's like a duty I have to perform before I can continue with life. the stairs are the worst—I only do it at night, although the thought pops into my head every time I have to walk up or down them. It is at night when everyone is home. so I have to pick my time and walk softly. I feel everyone else is controlling when I can do it, trying to stop me. Just leave me alone and let me finish. I have to get it done! I can't live, I don't know how to live without them. If I don't do it I will be a self-indulgent, fat, lazy slob. When I'm tired, my thoughts are fuzzy, so I can't figure them; when I'm alert I have enough energy to run across the Nullabor. Let me do them, get it over and done with, put it behind me, let it be over for another night. Quickly, quickly, faster and faster. Sometimes I feel so ashamed of myself for doing this—I just close my eyes or focus on how good it will be when it's all over. It's so lovely. My awareness is heightened, I can hear everything and feel everything and gosh, it hurts. Stop it, time out, defocus on what's around and just feel the ache in my legs. Just let me keep going, go and have your shower so I can do it knowing no one will interrupt me. I hate interruptions. It makes me lose count. It's cool when everyone is out or in bed—I can just go hellfire, another priority completed for the day. I'm so angry. Faster, faster, harder, harder, block everything but just keep counting. It's so insidious, like this urgent, desperate, persistent itch going on in my head, slowly becoming a roar so loud that reality is blocked out. Nobody listens, nobody hears, nobody changes. Everything is o bloody frustrating I can't ever scream out my anger because society reads it as a sign of needing help or having totally lost the plot. So what was simple frustration is now multiple compounded frustration and my head is paralyzed, despite wanting to be bashed against a brick wall."
The outcome of anorexia nervosa
The aims of treatment are: first, to help the woman achieve a weight within the normal body weight range, that is, a BMI of 19 or more; second, to help her to eat normally for her age and lifestyle; third, to enable her to avoid extreme methods of weight control; fourth, to enable her to gain insight so that she no longer needs her eating disorder to help her cope with problems of her daily life; fifth, to help her to improve her body image and body concept so that it no longer depends on her body weight.
Between 50 and 75 per cent of anorexia nervosa patients achieve these aims completely or partially after treatment lasting six months to six years. In other words 40–50 per cent of sufferers from anorexia nervosa will recover completely, and 30–40 per cent recover sufficiently to lead a normal life, although they may continue to have thoughts or behaviors that are associated with an eating disorder.
Recovery is more likely if she is younger, is not at very low weight, if it is the first time she has received treatment, treatment is started early, if the woman's family is supportive, if there is no conflict between family members, and if the woman was a ‘dieter’ rather than a ‘vomiter and purger’. Unfavorable factors are a profound loss of weight, and if anorexia nervosa is associated with bulimia nervosa.
Many women who have apparently recovered may continue to need support in the following years and should know that they can obtain counseling and psychotherapy should they feel they need it.
Kylie's story typifies the problem. In the previous three years she had had four admissions to hospital for refeeding. Each admission had lasted for at least two months. After being discharged from hospital for the fourth time she wrote to the doctor: "I know that I still look too thin, but I just don't seem able to regain the weight I lost in the last four months. It may be because I left home then. I was very worried about how I'd cope when I started living away from home again, and tried to be strict with myself about ‘cutting back’ on food. I don't think I did ‘cut back’, but suppose I'm a lot more active now at work than I was when I was at home leading a life of (enforced) leisure. However, I find it almost impossible to let myself eat more. As you may remember, my problem has always been an ‘eating-food’ one, rather than a concern with weight. Basically I still think the same way as I have for a long time, and I don't suppose this will ever change now.
Anorexia now seems to be becoming increasingly common, and receiving a lot of publicity. I don't know whether the publicity is all for the good—I have the feeling it may be becoming almost ‘fashionable’ among young girls, without their realizing its long-term consequences. If I could but turn the clock back about twelve years; wishful thinking!"
A year later, Kylie wrote again: "Considering everything, I've been keeping quite well. I've maintained my weight since I left the Clinic (over a year ago now!) though I haven't put any more on. I'm still not over-confident about how I would cope on my own, i.e. if I was preparing and responsible for all my own food. So many of the old attitudes are still lying dormant and I have to be ever vigilant that they don't exert too much influence. All in all it's still not terribly easy, though I must admit that I do think less and less about being an ‘anorexic’."
The remaining 15–25 per cent of anorexia nervosa patients continue to suffer from anorexia nervosa, requiring intermittent therapy over many years. The last two groups of patients require the support of, and to be counseled by, a therapist at intervals for several years after refeeding, because life and developmental stresses may precipitate a recurrence. Refeeding, re-education of eating habits, and explanation of physical symptoms are only initial goals in the treatment of anorexia nervosa.
Helping the woman to understanding what is happening and to give her reassurance about these matters and her beliefs about eating is equally important. Although this information is given during the refeeding period, most patients have more insight and understanding about their feelings and behaviors as their weight approaches or is within the normal weight range. In these sessions the aim is to help the woman continue to escape from the preoccupation with weight gain and food that she had when she was ill, and help her cope with life stress and other problems which may arise, without resorting to her previous disordered eating behavior.
Continuing therapy may have to be available for many years. This means that the woman may need to know that she can contact her therapist and make an appointment or a series of appointments even if she has not had treatment for months or years.
Death due to anorexia nervosa gets newspaper headlines, particularly if a celebrity such as Karen Carpenter is the victim. However, fewer than 3 per cent of patients die from the effects of the eating disorder (half of whom die following a drug overdose). In short-term studies, predominantly of adolescent women, the death rate is 0–2 per cent. Long-term studies, which include the 20 per cent of chronic anorexia nervosa sufferers, suggest that up to 6 per cent of these patients will die over a period of years. However, with a greater community awareness about anorexia nervosa so that victims seek help earlier in the illness, and more physicians trained to manage the illness, the death rate is decreasing and is likely to be lower in the next decade.
- Abraham, Suzanne; Llewellyn-Jones, Derek; Anorexia nervosa; Eating Disorders (Oxford), 2001
The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #8
The preceding section contained information
about relapses and outcomes in Anorexia Nervosa. Write
three case study examples regarding how you might use the content of this section
in your practice.
What percentage of clients with anorexia successfully recover? Record the letter of the correct answer