Coping With Relapses in Bulimia Recovery

(When bulimia relapses—or lapses—happen)

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Relapses happen and are discouraging when they do. However, they don’t mean that you’ve failed or that you won’t ever be fully recovered. These set-backs are actually a normal part of the recovery process and offer the opportunity for both learning and strengthening recovery.

Let’s first define the terms: A lapse or slip is the occurrence of a minor symptom while a relapse refers to a recurrence of frequent binge eating or purging.

Because a lapse is a single event it does not necessarily lead to a relapse. Additionally, how one responds to a lapse plays a big role in whether it becomes a relapse.

Let’s look at the data: Relapse rates for clients successfully treated for bulimia nervosa range from 31% to 44% during the first two years of recovery. So, if you have experienced a relapse, you are in good company.  Some studies have tried to identify features of the client that predict relapse (such as calorie restriction, symptoms at discharge, and body image disturbance); however, in my clinical experience, I’ve come to believe that a more helpful line of research might be looking at the contribution of stressful life events to physical and psychological symptomatology (and relapses).

A study by Grilo and colleagues (2012) examined the relationship between stressful life events and relapse among patients with bulimia nervosa and eating disorder not otherwise specified (AKA EDNOS, the category now known as other specified eating disorder).

In this study, researchers administered the Life Events Assessment, an instrument which assesses 59 negative events and 23 positive events categorized into stress domains including work, school, social/friendship, love, family, health, and financial. This study found that negative stressful life events, in particular higher work stress (e.g., serious difficulties at work; laid off or fired) and higher social stress (e.g., broke up with or lost a friend), increased the likelihood of relapse.

These same factors have been found in other studies to negatively impact other health outcomes (e.g., susceptibility to the common cold). 

In my clinical work with clients dealing with lapses and relapses, I find it helpful to look at a similar instrument, The social readjustment rating scale, a checklist of 43 stressful live events. This measure was published in 1967 by Holmes and Rahe. The purpose of the inventory was to catalog environmental events that had been identified in patients’ charts as frequently preceding the onset of psychiatric illness. A panel of judges assigned Life Change Unit (LCU) scales to these events. The scale included such events such as: death of a spouse (assigned the highest LCU score of 100), death of a close family member (63), pregnancy (40), change in financial state (38), and child leaving home (29). Even events normally  considered positive, such as marriage (50), are included because each are often associated with stress.

When they published the scale, Holmes and Rahe reported that events were additive.

Thus, if your spouse died and left you with no income and a child left home at the same time, your LCU score would be 100+40+29 = 169. The researchers stated that a score over 300 put someone at risk of illness. A score of 150 to 299 indicates moderate risk of illness (30% less than the higher category). A score below 150 is associated with only a slight risk of illness.

The Holmes-Rahe model has been criticized primarily for its failure to take individual difference into consideration. The scale assumes that each stressor affects people the same way, which is not necessarily true; for example, some people may find divorce extremely stressful, while for others it can be a relief.

While it may not be a psychometrically sound instrument, I nevertheless find it useful clinically to help clients understand when and why relapses may have occurred. The quantification of life events helps clients to see stressors to which they may have given little attention. If you have had a relapse recently, it is worth checking out this measure, which can be self-administered, and considering whether you can identify recent stressors in your life.

Often when clients experience a return of symptoms, it is following stressful life events and/or transitions such as going to college or starting a new job. This is not surprising – entrenched maladaptive behaviors come back when one feels overloaded or facing an unfamiliar environment and newer healthier coping skills have not yet become as ingrained.

If you have had a recent relapse it is important to review what has happened and make a plan to get back on track. How you respond to a lapse or relapse is actually more important than that the lapse occurred. Addressing it early and diligently can prevent a single lapse from becoming a relapse or from truly derailing your recovery.

Here are some suggestions for what you can do: 

  1. Recognize and acknowledge that the lapse or relapse has happened
  2. Don’t beat yourself up; practice self-compassion
  3. Resolve to get back on track.
  4. Reach out for help from your support network and/or treatment team.
  5. Try to identify what factors contributed to the lapse/relapse and how you can handle similar triggering situations in the future. 
  6. Identify what techniques and coping strategies that helped you with recovery in the past you could employ again (e.g. completing food records, more diligent meal planning, etc.). 
  7. Consider going back to treatment maybe even for a booster session or two.

In most cases, treatment following a lapse or relapse is briefer than the original treatment, and soon you are likely to be well back on the recovery path. 

References: 

Brownell, K. D., Marlatt, G. A., Lichtenstein, E., Wilson, G. T. (1986). Understanding and preventing relapse. American Psychologist, 41, 765-782.

Dohrenwend, B.P. (2006). Inventorying Stressful Life Events as Risk Factors for Psychopathology: Toward Resolution of the Problem of Intracategory Variability, Psychological Bulletin, 132, 477–495.

Grilo, C.M., Pagano, M.E., Sout, R.L., Markowitz, J.C., Ansell, E.B., Pinto, A., Zanarini, M.C., Yen, S., Skodol, A.E. (2012).  Stressful life events predict eating disorder relapse following remission:  six year prospective outcomes. International Journal of Eating Disorders, 45, 185-192. 

Halmi, K.A., Agras W.S., Mitchell, J., Wilson, G.T., Crow, S., Bryson, S.W., Kraemer, H. (2002). Relapse predictors of patients with bulimia nervosa who achieved abstinence through cognitive behavioral therapy. Archives of General Psychiatry, 59, 1105-9.

Holmes, T. H., & Rahe, R. H. (1967). The social readjustment rating scale. Journal of psychosomatic research, 11, 213-218. 

Marlatt, G. & Gordon, J.R.. (eds.), Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, Guilford, New York, 1985.

Olmsted MP1, Kaplan AS, Rockert W. (1994) Rate and prediction of relapse in bulimia nervosa. American Journal of Psychiatry.  151, 738-43.

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