Body of Evidence

Dispatches from the forefront of eating disorder science

Rethinking Recovery

An eating disorder is my Achilles' heel.

In yesterday's Health section of the New York Times, writer Abby Ellin (author of Teenage Waistland) published an article titled In Fighting Anorexia, Recovery Is Elusive. In her article, Ellin writes:

Like many patients with eating disorders, however, she is not sure what recovery means.

"Does it mean ‘functional?' " asked Dr. Dooley-Hash, 45. "I'm a physician at a really high-powered institution, and I've published in well-respected journals - I'm functional. I don't think functionality is necessarily a good measure."

{snip}

So the big issue is, how do you define recovery? Maintaining a normal weight, recurrence of menstruation is easy to document. Mental status is a different problem.

With that in mind, many with anorexia prefer to view recovery as many alcoholics do - the disease may be in remission, but the potential for relapse always lurks in the background.

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The reaction of the eating disorder community (composed of therapists, psychiatrists, dietitians, clinicians, parents, and current and former sufferers) has run the gamut from a pretty accurate description of the clinical picture to utterly depressing.

Part of the problem with assessing the accuracy of the article is that no one has defined what eating disorder recovery actually is. For that matter, the eating disorder field is still struggling to define what an eating disorder itself is, let alone what recovery might look like. Quantitative questions like weight and menstrual status are relatively easy to ask.

Not that we shouldn't ask these questions, but we also shouldn't expect them to tell the whole story. If weight isn't the sole arbiter of the seriousness of an eating disorder, then it can't also be the benchmark of recovery. Weight restoration (if necessary) and normalization of eating habits are just the first step in eating disorder recovery. Only with nutritional rehabilitation can you begin to address other psychological issues like anxiety, depression, and trauma.

I think some of the reason the eating disorder community struggles with defining recovery is that so much disagreement still exists on what causes eating disorders. If an eating disorder is "about" control or a maladaptive coping mechanism, then understanding why you developed the disorder can essentially cure you. But a growing number of studies are showing that someone's vulnerability to developing an eating disorder is inborn. These vulnerabilities--perfectionism, anxiety, impulsivity--existed long before the eating disorder and will likely exist long after.

Like Dr. Daniel LeGrange said in the article, an eating disorder is someone's Achilles heel. Relapse remains a possibility for anyone with an eating disorder history, and we would be blind if we didn't prepare people for the possibility that the illness would return.

What I think gets lost in the discussion--what I don't think gets emphsized enough--is that preparing for the possibility of relapse doesn't mean spending every waking hour fighting eating disordered thoughts and symptoms. Instead of referring to "recovery," physician Julie O'Toole, founder and director of the Kartini Clinic in Oregon, refers to eating disorder "remission." Just like cancer, a person with an eating disorder can have no detectible signs of illness. Other than periodic tests and check-ups, the person lives a normal, healthy, disease-free life. But experience has taught oncologists that cancer can return. We don't need to be afraid of it, but we do need to prepare for it.

I remain optimistic that full recovery is possible in many people with eating disorders, especially if caught early and treated aggressively. I've seen many people turn their eating disorder from a life-consuming illness into a piece of their past. I've also seen happy, well-adjusted former sufferers relapse through no fault of their own.

 An eating disorder doesn't just go away. It's not a cold. One bout with an eating disorder doesn't leave you "immune" to further onslaughts. I have friends from high school who have asked me if I was "over it" yet. A chronic eating disorder isn't something you just get over. It's not something you forget about like the stomach flu or a broken ankle. As much as I intend to one day refer to my eating disorder in the past tense, I also know that I need to keep my recovery very much in the present tense no matter how long it's been since I counted calories or could see my thighs magically expanding after eating cake.

Carrie Arnold is in recovery from a decade-plus battle with anorexia and is working on her third book, Decoding Anorexia: How Science Offers Hope for Eating Disorders.

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