The current findings provide evidence that full recovery from an eating disorder is possible, including the attainment of normal attitudes toward food and the body. This suggests that prior findings that residual symptoms often persist in those recovered from an eating disorder may be an artifact of an incomplete definition of recovery. We found that those who no longer meet criteria for an eating disorder, who have not engaged in bingeing, purging, or fasting in the past three months, who have a BMI of at least 18.5, and who score within 1 SD
of age-matched community norms on all the EDE-Q subscales appear to have attained full recovery, and were indistinguishable from healthy controls on a wide range of disordered eating measures that focused on cognitions related to body image, eating, and food. In contrast, a partially recovered eating disorder group that was recovered physically and behaviorally, but not psychologically, was similar to an active eating disorder group, in terms of disordered eating cognitions. It is noteworthy that the partially recovered and active eating disorder groups did not differ on body image-related measures, but fully recovered and active eating disorder groups did. This finding is consistent with prior work where only individuals who were both cognitively and behaviorally recovered looked comparable to controls in terms of body dissatisfaction and endorsement of the thin ideal (Bachner-Melman et al., 2006
). It appears as though body image disturbances may be key to distinguishing between partially and fully recovered individuals, and that a healthier relationship with one's body may be the final hurdle in recovery.
In terms of functioning in specific psychosocial domains, partially recovered, fully recovered, and healthy control groups functioned at comparable levels. These findings provide some optimism that even if a partially recovered individual maintains eating disorder attitudes similar to her active eating disorder peers, she may function similarly to those with no eating pathology in terms of psychosocial adjustment. There was some evidence that only healthy controls and fully recovered individuals functioned better than active eating disorder individuals in some relationships (with father, friends).
To some degree, it was surprising that 12% of the fully recovered group reported that aspects of the eating disorder had interfered with psychosocial functioning in the past three months. However, this percentage is markedly less than the 40% for the partially recovered group and the 73% for the active eating disorder group. For a minority of the otherwise fully recovered individuals, there may be some scar effects of the eating disorder. It could also be that in some cases the eating disorder interference in relationships was due to others continuing to express concerns that may be unwarranted – for example, a mother pushing her daughter to eat more when the daughter has eaten a reasonable meal and is sated, leading to tension. Of note, participants reported if eating disorder aspects had ever interfered in various domains across the past three months, so individuals for whom this had happened once were grouped with those for whom it had happened frequently. Future research should assess eating disorder interference as a continuous rather than dichotomous variable. Also, future work should incorporate more tailored measures of psychosocial impairment secondary to disordered eating attitudes and behaviors and make use of new quality of life instruments (Bohn, Doll, Cooper, O'Connor, Palmer, & Fairburn, 2008
; Engel, Adair, Las Hayas, & Abraham, 2009
In terms of Axis I disorders, there was evidence for the fully recovered group looking both similar to controls (in terms of percentiles with a current mood disorder) and more pathological (in terms of percentiles with a current anxiety disorder). These results fit with existing work suggesting that anxiety disorders tend to precede eating disorders (Kaye, Bulik, Thornton, Barbarich, Masters, & Price Foundation Collaborative Group, 2004
), but depressive disorders are more often a consequence or concomitant of eating disorders (Herpertz-Dahlmann et al., 2001
; Wentz, Gillberg, Gillberg, & Rastam, 2001
). Interestingly, the fully and partially recovered groups had similar proportions of individuals with an anxiety disorder (about one-third). It could be that for those who are fully recovered but with a current anxiety disorder, the underlying pathology that may have driven both an eating disorder and an anxiety disorder continues to be expressed, but only in the domain of non-eating disorder related anxiety. Overall, the partially recovered and active eating disorder groups, but not the fully recovered group, were significantly more likely to experience current non-eating disorder pathology than healthy controls.
This study contributes to the literature with its theoretical conceptualization and operationalization of eating disorder recovery, along with a validation of this way of defining recovery. Thus, this work follows recommendations in the depression literature related to empirically validating a proposed category of recovery (Frank et al., 1991
). It is also one of a limited number of recovery studies assessing non-eating disorder psychopathology and psychosocial functioning, and one of the few focusing on quality of psychosocial functioning rather than status variables. Generalizabiltiy is also a strength; by sampling from a facility other than an eating disorder clinic we were able to study a group with greater variability of severity – our sample included individuals with diagnosable but less severe eating disorders as well as individuals with multiple hospitalizations. Finally, it is a strength that the healthy controls were determined only by absence of a past or current eating disorder, rather than by absence of any past psychopathology which would create “super healthy” controls that are less representative and against which it would be easier to find group differences (Klump et al., 2004
In terms of limitations, all data were self-report (albeit via a combination of interview and questionnaires) and the sample size was relatively small. We note that we were not able to contact a significant minority of individuals. Some of the particular challenges in locating young women for follow-up, in some cases over 10 years since their last clinic visit, included women who married and changed their last name as well as the now widespread use of mobile phones for which numbers are not recorded in any accessible registry. Of those we were able to contact, the majority did participate and no significant differences were found between participants and non-participants on relevant measures such as eating disorder diagnosis. It is also a limitation that the healthy controls were younger than the other three groups and that the participants were homogenous in terms of demographics. Future work should ensure that comparison groups are age-matched and should include males and greater racial/ethnic diversity for better generalizability. Another limitation is the cross-sectional design, which provides a snapshot of what is a dynamic process. Prospective, longitudinal research is needed to understand movement across eating disorder stages, to better assess the degree of severity during the active phase of an eating disorder that might predict recovery outcome, and to identify who relapses, thus providing further tests of the validity of this definition of full recovery. Finally, it may be argued that lumping together AN, BN, and EDNOS is a limitation, especially given evidence of different temporal patterns of recovery for AN and BN (Von Holle et al., 2008
). Others may argue that this is an appropriate approach given eating disorder diagnostic migration (Tozzi et al. 2005
) and the common core pathology of overvaluation of weight and shape (Fairburn, 2008
). Future research with larger samples will want to examine these groups separately in order to determine if there are differences in predictors of comprehensive recovery for different eating disorder diagnoses.
The finding that full recovery exists is important information for practitioners and eating disorder patients and their families so that they have a sense of what recovery can look like. Given that the fully recovered and partially recovered individuals differed in terms of body shame, appearance schemas, and thin-ideal internalization, these may be fruitful targets of intervention among those on a recovery trajectory. Also, given that individuals fully and partially recovered from eating disorders reported elevated rates of current anxiety disorders and given the biological and genetic underpinnings of eating and anxiety pathology (Kaye et al., 2004
), practitioners working with individuals with eating disorders may want to make sure that anxiety symptoms are also a focus of treatment. What needs to occur for full recovery, namely, psychological recovery in addition to physical and behavioral recovery, also has implications in the context of managed care. While future prospective research needs to determine whether those fully recovered are at significantly lower risk for relapse than those partially recovered, should this be borne out, then insurance companies should cover services that facilitate comprehensive recovery in order to reduce the revolving door phenomenon of eating disorder relapse. Finally, the findings also have implications for the definition and assessment of full recovery. Using the EDE-Q, BMI, and an assessment of binge eating, purging, and fasting among those with a past, but not current, eating disorder appears to be a logistically practical way to identify meaningful recovery that is cost-effective and efficient time-wise.
In sum, full recovery from an eating disorder appears to be a realistic goal, with future research needed to determine for whom it is a more realistic goal than for others. The inclusion of an explicit psychological piece of recovery is critical for identifying a more meaningfully recovered group that should be at low risk for relapse in what are often seen as chronic disorders. Future research should prospectively follow these recovery groups to provide further validation of the current operationalization of recovery and to identify predictors of trajectories. For example, longitudinal research could elucidate what predicts someone in partial recovery progressing to full recovery, staying in partial recovery, or relapsing. Factors such as coping skills and social support should be examined as potential contributors to full recovery (Bloks et al., 2004
). Given the need for researchers to agree on a definition of eating disorder recovery (Walsh, 2008
) and the desirability of finding a definition of full recovery that is valid, based on psychometrically strong measures, and easily applied, we propose that the current operationalization is a promising approach that is both meaningful and practical. Thus, rather than arguing that other operationalizations should not be considered, we propose that researchers interested in examining eating disorder outcomes should design their studies to allow them to operationalize recovery as proposed in this paper.