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Relapse Prevention: Once Is Enough
By Catherine Pearte, Elizabeth Wack & Stacey Tantleff- Dunn, PhD
Reprinted from
Eating Disorders Today
Spring 2007 Volume 5, Number 2
©2007 Gürze Books
Preventing relapse is a critical component for treating anorexia nervosa (AN) and bulimia nervosa (BN). While the onset of these disorders can be devastating to both the patient and the patient’s family, diagnosis often marks the beginning of an insidious cycle of recovery and relapse. This cycle occurs in approximately one-third of patients, with relapse beginning as early as 7–15 months after initial recovery.
Relapse can be described as the manifestation of symptoms after a period of recovery. Symptoms of relapse include weight loss, compensatory behaviors, and deviant attitudes regarding weight and shape. For example, AN patients who initially restricted their caloric intake sometimes develop bulimic symptoms during relapse. Because of the psychological distress and the threat of mortality posed by eating disorders, scientific attempts have been made to predict and prevent relapses that have become all but characteristic of the chronic course of eating disorders.
Researchers have recently begun to emphasize the importance of identifying factors that may predispose patients to relapse. Although the symptoms of AN and BN sometimes overlap and can be treated with the same psychological and pharmacological approaches, factors that contribute to relapse are different in patients with AN as opposed to BN.
Relapse Risk Factors for AN
• Early age of onset
• Lower desired weight
• Duration of illness
• History of suicide attempts
• Obsessive behaviors
• Bingeing before the end of treatment
• Treatment at a nonspecialized clinic
• Previous treatment for an eating disorder
• Absence of treatment during follow-up
Relapse Risk Factors for BN
• Low motivation for treatment
• Absence of treatment during follow-up
• Stressful or difficult circumstances
• Anxiety, nervousness, or depression
Therapies, Medication, and Technology
The gravity of the medical and psychological consequences left in the wake of eating disorders have spurred researchers to conduct trials using specialized therapies, medication, and technology to determine how to best protect patients from relapse. However, there is limited research available to attest to the success of any particular relapse prevention strategy. Several studies have concluded that individuals who remain in therapy after recovery fare better than those who do not receive ongoing therapy. The continuing support of a mental health care professional is important for sustaining patients through the very difficult initial weeks of recovery wherein adjustment to new routines and, in the case of AN, the additional weight, can be a frightening, lonely, and overwhelming ordeal.
Antidepressants
Although research indicates that anti-depressant medication may be beneficial in the treatment of a variety of eating disorders, there is less scientific support for the efficacy of anti-depressant medications, specifically Prozac (fluoxetine), in relapse prevention. A 2006 study did not find any difference in relapse rates after 52 weeks among patients who were receiving cognitive-behavioral therapy between those who in addition took Prozac and those who in addition took a placebo.1 This is a particularly disappointing finding considering that if anti-depressants were found to be effective in preventing relapse, partially recovered BN and AN patients who often experience high levels of depression could use the medication to jointly alleviate depressive symptoms and lower their likelihood of recurring eating disturbance.
Text Messaging
Medication and psychotherapy are the most common techniques employed in an effort to prevent relapse, but relapse prevention also has been attempted in a rather creative manner, utilizing a particularly prevalent and accessible form of technology: cellular phones. One study was conducted in which researchers tested the feasibility of using text messaging as a form of aftercare communication aimed at preventing the return of bulimic symptoms in patients recently discharged from a treatment facility.2
Participants were asked to send a weekly text message to their treatment team addressing five questions about their symptoms and mood state. In return, the team responded each week with advice and support. Although its impact on relapse rates has not yet been assessed, patients expressed that the text messaging made them feel supported post-treatment. More research on the efficacy of this and other innovative approaches is needed.
An Integral Component
Although there has been some effort in the scientific community to identify risk factors and fight relapse directly, there is minimal success documented in the current literature. The medical and psychological consequences of chronic, long-term eating disorders highlights relapse prevention as an integral component in the treatment of eating disorders and an important subject for further scientific investigation.
References
1. Walsh, T.B., Kaplan, A.S., & Attia, E. (2006). Fluoxetine after weight restoration in anorexia nervosa: A randomized controlled trial. Journal of the American Medical Association, 295(22), 2605-2612.
2. Bauer, S., Percevic, R., & Okon, E. (2003). Use of text messaging in the aftercare of patients with bulimia nervosa. European Eating Disorders Review, 11(3), 279-290.
Catherine Pearte and Elizabeth Wack are doctoral students who work with Dr. Stacey Tantleff-Dunn in the Laboratory for the Study of Eating, Appearance, and Health at the University of Central Florida in Orlando.
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