Defining recovery: Life after an eating disorder
So we’ve finally come to the last part of the Defining Recovery series, in which I want to look at what happens to women after recovery. Stopping ED behaviors is, in a sense, a means to an end, which is the creation of a healthy, meaningful life. There’s no real way to get at what that meaningful life is, nor does it particularly matter. Everyone has their own definition. But is it possible to look at a group of former ED sufferers and tell whether they were once affected by an eating disorder?
The answer, as with some many things, is that it depends, both on the particular group of people being studied and on what factors you’re looking at.
Perfectionism is a feature common to many eating disorders (read more about what perfectionism is and how it relates to body image here). Many patients report high levels of perfectionism both before and during the disorder, which has led researchers to believe that perfectionism is a significant risk factor for the development of an eating disorder. It definitely was for me! The question that remains, however, is does this perfectionism persist after recovery. The data are somewhat mixed, but there does seem to be some indication that people with a history of EDs are more perfectionistic than those who have never had an eating disorder, although levels of perfectionism seem to improve with recovery.
In a study in the International Journal of Eating Disorders, Anna Bardone-Cone and colleagues compared fully and partially recovered women on different aspects of perfectionism (Bardone-Cone et al., 2010). The researchers recruited 96 women who were current or former patient at a Missouri eating disorder clinic. Of these, 53 had a current ED diagnosis, 15 were partially recovered, and 20 were fully recovered. They were assessed both on levels of eating disorder symptoms and on a variety of different measures of perfectionism.
The fully recovered group looked almost identical to the healthy controls in all measures of perfectionism. On the other hand, the partially recovered group looked much closer to the active eating disorder group. This could mean that perfectionism is one of the last factors to change in an eating disorder. It could also be that recovery is what enables the relaxation of perfectionistic standards.
These findings are in contrast with other previous work that found perfectionism remained elevated even after recovery. Whether this is due to differences in definitions of recovery, the aspects of perfectionism evaluated, or just the vagaries of sample collection remain to be seen. I would love to see this work replicated to see exactly what’s going on here.
Other personality characteristics
Perfectionism is a major personality trait in many (though not all) people with EDs, but it’s hardly the only one that researchers have found to be significant. Some research on personality traits pre- and post-ED comes from a genetics study funded by the Price Foundation (Klump et al., 2004). Using information on 358 pairs of relatives with EDs (AN, BN, or EDNOS), researchers defined recovery as being ED symptom-free for at least one year. They assessed personality using Cloninger’s Temperament and Character Inventory.
Temperament refers to those parts of our personality that are largely innate. In the TCI, there are four aspects of temperament: harm avoidance, novelty seeking, reward dependence, and persistence. Character is seen as much more flexible and a “nurture-based” aspect of personality. The TCI measures three different aspects of character: self-directedness, cooperativeness, and self-transcendence.
Although some areas of temperament and character changed after ED recovery, in many areas, there wasn’t much of a shift. The researchers found high levels of harm avoidance in people with EDs, both pre- and post-recovery. They also had decreased levels of cooperativeness. Novelty-seeking was highest in women with current and previous BN, although novelty-seeking did significantly increase in people with AN after they recovered. In terms of overall temperament and character traits, women recovered from an ED did look significantly different than healthy controls in certain, specific areas, especially harm avoidance, novelty seeking, and cooperativeness.
Interestingly, women who have recovered generally look pretty similar in terms of personality traits. Put another way, women with a history of ED more closely resemble each other than women who have never been ill (the studies done thus far have really looked only at women with EDs). Researchers compared personality traits using a variety of questionnaires on depression, anxiety, the TCI and more in 60 women recovered from AN and BN (Wagner et al., 2006). They found that although levels of depression, anxiety, personality disorders, and TCI traits in the recovered women were all significantly elevated or different from those in control women, they didn’t differ between the ED diagnosis. Based on personality traits, the researchers divided the recovered women into two main clusters: Cluster 1 had higher levels of impulsivity, novelty seeking, and self-transcendence, while Cluster 2 had high levels of harm avoidance. Science of EDs has a more in-depth analysis of this study here.
What do former sufferers say?
One of the best ways to find out what life after recovery is all about is by actually asked people who are experiencing this. Two Swedish researchers asked 14 former eating disorder patients who had recovered to participate in an in-depth interview about their perceptions of recovery (Bjork & Alstrom, 2006). The participants were all female and between the ages of 22 and 34. They had been ill with their disorder between 1.5 to 12 years (avg. 5.5 years), and the breakdown of diagnoses were as follows: 4 had AN, 4 had BN, and 6 had EDNOS.
Before the researchers dove into the interviews, they noted the following:
The participants were very willing to share their thoughts and feelings about being recovered. Most of them had a lot to tell, and a rich volume of material emerged. A few of them, though, answered more brieﬂy. They just lived their new lives and did not devote much thought to recovery.
The latter part of this struck me as particularly interesting, and even reassuring. The women spoke at length on issues related to self-esteem, body acceptance, regular eating, and expressing their feelings.
A few of the quotes that spoke to me:
Yes, I’ve accepted my body. Not that I think I’m so ﬁne—I wouldn’t say I’m ﬁne and pretty, but I’ve accepted it. My body works, and it’s good enough. That’s what I think. Well, I’m not a slender little person, but that’s the way it is. So be it. (Lisa)
I try to do things for my own sake in another way, I think. Not that I’m a superegoist and always put myself ﬁrst and think I have a right to everything and so on. It’s more like, say, “I don’t feel like doing anything this Sunday, I’ll just read a book in the bath.” So that’s what I do now and then, treat myself to a bit of relaxation in a way I couldn’t before. (Elizabeth)
Nowadays I can see that people mean an awful lot to me. I see them. I’ve come to understand, too, that I’ve neglected them—not in such a way that I have a bad conscience about it, but I do understand now that, God, they mean a lot to me. I hadn’t seen it before, or anyway hadn’t properly realized it. I hadn’t realized how important it was, which I do now. (Helen)
Ultimately, the researchers concluded:
Regarding their present lives, the participants expressed hope, pleasure, and a sense of freedom. It was clear that they separated life in the present from life in the past. Recovery meant dealing with the eating disorder that earlier had ﬁlled their lives, rejecting disordered eating behavior, and no longer having the identity of a person with an eating disorder. They now felt they belonged to the healthy instead. Even though the participants realized that there was a risk of their relapsing, they did not see themselves as going back to a life dominated by an eating disorder. The reason was that they now valued their new life very highly, as worth caring about.