Relapse Prevention and Changing Habits in Anorexia Nervosa

Written by Joanna Steinglass, MD, and Julia Ruggiero, BA.

The path to full recovery from anorexia nervosa can feel overwhelming at times. There are so many different ways that the illness can sneak into life during or after treatment – patterns of daily activities that have the consequence of making meals smaller, or less frequent, or increasing activity levels. Sometimes these are unintended consequences, but somehow the behaviors that serve the eating disorder have become deeply rooted, hard to change, routines. Studies show us that even after people successfully do the hard work to get renourished in intensive treatment programs, for many, symptoms persist or return, and relapse rates are disappointingly high (upwards of 50%).

The need for better treatments is clear. So clear that the National Institute for Mental Health (NIMH) recently issued a call for researchers to develop the kinds of treatments that will help people after they have completed a treatment program, and the kinds of treatments that can reach more people in need. Needless to say, as a research program committed to better understanding eating disorders and improving treatment, this was right up our alley!

At the Columbia Center for Eating Disorders, we have a new plan to specifically help patients with the entrenched, unhelpful routines (or, habits) that make it hard to recover from anorexia nervosa. Our research has shown that there are neurobiological explanations for the challenges people face in trying to maintain health. Patients with anorexia nervosa are using different parts of the brain when they decide what to eat – parts of the brain that serve more habitual behavior. And, we have found that by focusing on these habit-like behaviors, we can help people develop new, more health-sustaining routines. To do this, our team is studying a new treatment, Relapse Prevention and Changing Habits (REACH+).

What is a habit?

In social science terms, “habits” have a very specific meaning. These are routines that have been learned (so, not reflexes), occur frequently, and occur somewhat automatically. Neuroscientists also add to this definition that you know it’s a habit because it happens even when your goals may have changed.

Habits are set off by certain cues in the environment, not necessarily because of beliefs about what you want to happen. For example, maybe you are someone who likes to wear a hat on a sunny day. Every day of summer you put on your hat as you walk out the front door. After a while, you don’t need to think about it and you might find that you walk out the door with your hat on, even though summer has turned to fall and it’s a cloudy day. This particular habit just means that you have an extra hat. However, some habits can cause considerably more trouble.

For many people with anorexia nervosa, their eating habits changed early on at a time when they had a particular goal in mind. This may have been a desire to “eat healthier,” run faster, or lose weight. Early on, the changes in eating patterns may have felt rewarding in some way – often in very personal ways.

Reward can take different forms including

• external praise
• internal pride
• or internal quieting of anxiety

No matter the form, rewards reinforce – or strengthen behavior. As an eating disorder like anorexia nervosa develops, these rewards reinforce dieting and exercising behaviors, and the behaviors then get repeated. Over time, the behaviors get repeated a lot, anorexia nervosa develops, and dangerous weight loss occurs. By this point, the initial rewards may not matter so much anymore – anxiety might not be calmed, the praise may have stopped – but the cues in the environment (the kitchen table, the mirror) nonetheless still set off a series of actions.

In other words, when an individual engages in these behaviors repeatedly and over a long period of time, the act of dieting may become automatic in some ways, such that the previously-rewarding outcome doesn’t really matter; persistent, repeated restrictive eating has become habitual.

How can we help?

Building off of our findings on habits in anorexia nervosa, we have developed treatment interventions that specifically target these kinds of routines.

In our first study, patients with anorexia nervosa who were receiving inpatient treatment with us received a psychotherapy intervention that focused on the habits they noticed during treatment. Together, the patient and clinician identified the cues that set off the behavior and looked for easy ways to break the behavior chain. Treatment also focused on identifying the positive outcomes or feelings that accompanied behavior change. By spending time noticing the new rewards, it becomes easier to repeat these new, more adaptive routines. The study showed that doing this treatment decreased habits, decreased eating disorder symptoms, and even improved actual eating.

Now, we have answered the call from NIMH and developed a new habit-busting research treatment for patients with anorexia nervosa after they have completed our inpatient program. Patients often tell us that they can follow the treatment plan during a program, but returning home sometimes returns them to old cues and routines, making relapse more likely. REACH+ is aiming to help people during a critical window in their recovery – the transition following hospitalization – to catch and tackle those sticky habits that can feel impossible to shake.

REACH+ offers 6 months of telehealth outpatient treatment with one of our expert eating disorder clinicians. The main focus of treatment is changing problem behaviors and habits. To do that, patients and therapists address the behaviors directly, as well as addressing thoughts about eating, shape, and weight. In between sessions, patients will use an online platform designed specifically for this treatment. Because we know that people have different learning styles and preferences, the platform contains audio resources, video recordings, and written educational materials. This online platform will also be used for session materials, like worksheets on staying motivated, challenging habits, and logging eating patterns.

How can I get involved in REACH+?

REACH+ is a study treatment for patients who have finished our weight restoration treatment program. So, the first step is to speak with our team about treatment at the Eating Disorders Research Unit. [If you have questions about what it means to receive care through a research program, please check out this post on frequently asked questions.]

Treatment on our inpatient eating disorders unit at the New York State Psychiatric Institute is provided at no cost.

To be eligible for the study, participants must be between 18-60 years old, have a diagnosis of anorexia nervosa or, if not formally diagnosed, believe they might meet criteria.

If you or someone you know is interested in participating, don’t hesitate to reach out to us at 646-774-8066 or edru@nyspi.columbia.edu.

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