How to Recover From Anorexia

by | Mar 11, 2024 | Anorexia | 0 comments

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If you think you may have an eating disorder it is important to seek advice from your GP or health professional. The information in this blog post is intended for information purposes only and is not a substitute for personalised clinical advice. 

Do you want to know how to recover from anorexia? Perhaps you have started to feel as though food is controlling you, rather than the other way around.

If you’re reading this you might be unsure about where to begin or how to get better. In this guide, I’ll outline the process, covering everything from understanding what anorexia is, finding motivation for recovery, meal planning, self-help techniques and finding a therapist.  

Before looking at solutions, we need to understand what anorexia is and what keeps it going.

What is Anorexia?

Diagnosis

Anorexia nervosa is a serious eating disorder that leads people to be extremely fearful of gaining weight and severely restrict their food intake. Many people with anorexia will also use other behaviours to control their weight, for example exercising excessively.

To diagnose anorexia, healthcare professionals use two main manuals: the ICD-11 and the DSM-5. While the ICD-11 in the standard in the UK and Europe, the DSM-5 is predominantly used in the USA. Both include similar diagnostic criteria and include:

  • Persistent food restriction
  • Engaging in behaviours aimed at reducing energy intake (such as vomiting or exercising excessively)
  • An overwhelming fear of weight gain
  • Preoccupation with body weight and shape
  • Distortions to body image

Usually a diagnosis of anorexia is only given when someone is severely underweight, with a BMI below 18.5.  However, a period of rapid weight loss might replace this criteria. This is because people with initially higher BMIs can experience similar psychological and physical effects as those with lower BMIs.  

There are different subtypes for anorexia including a restrictive only subtype and a binge-purge subtype. These distinctions enable healthcare professionals to tailor treatment approaches to the specific needs of each individual.

Signs & Symptoms

There are several warning signs and symptoms of anorexia look out for. You might notice these in yourself or someone you know:  

  1. Following strict diets and extreme rules around eating.
  2. Rapid weight loss
  3. Low body weight
  4. Extreme fear of gaining weight
  5. Believing you are fat even if you’re significantly underweight.
  6. Constantly thinking about food, calories and weight.
  7. Feeling compelled to exercise, even if it causes injury.
  8. Changes in how you think, like being more focussed on details or more obsessional.
  9. Feeling depressed, anxious, or irritable.
  10. Physical symptoms including fatigue, dizziness, low sex drive, losing your period (in females).

Causes

The causes of anorexia are complex and usually involve a combination of factors. We know that some people are more vulnerable to developing anorexia due to genetic factors. For example, people are more likely to develop anorexia if they have a family member who has had anorexia themselves.

Social factors play a large role. Western culture places a premium of thinness, giving people with messages that their bodies aren’t good enough. Being in an energy deficit is a risk factor for anorexia, and diet culture therefore means people are more vulnerable to developing an eating disorder.

Anorexia can also be a coping mechanism for traumatic events in a person’s life. For example, pushing distressing emotions away by focussing on food or trying to feel safe by making their body unattractive to men.

Some personality traits are associated with anorexia. Those with a perfectionistic or detail orientated thinking style are more likely to develop difficulties with restrictive eating.

Recent research is indicating that about a third of people with anorexia also have autism, though the precise connection remains uncertain. One possible reason is that people with autism are more likely to stick to rigid dietary rules. People with autism are also more likely to experience high levels of anxiety and controlling food may be an attempt to reduce anxious feelings. 

What keeps it going

As well as knowing what led someone to develop anorexia, we also need to understand what is keeping people stuck. There are many cycles that can keep people trapped in an eating disorder.

I have drawn out some common cycles that people experience. By looking at these cycles we can see how easily someone find themselves caught in a downward spiral. But understanding these cycles also gives us pathways towards overcoming anorexia.

How to recover from anorexia

Motivation

First, let’s discuss readiness to get better. Motivation to recover from anorexia can fluctuate significantly. It’s normal to feel fed up with anorexia one day and frightened of change the next.

The Stages of Change model explains the stages that people go through when making any changes, including recovering from an eating disorder. Initially, you might not even realise there’s a problem (precontemplation). Then, you begin thinking about it (contemplation). Next, you get ready to make changes (preparation). After that, you actually start making those changes (action). Finally, you work hard to maintain those changes (maintenance). You can jump between stages as well as go through them step by step. The final step is relapse, where we learn from step backs and come back stronger and more resilient.

The Cycle of Change, adapted from work by Prochaska & DiClemente (1983)

In therapy for anorexia we will almost always start by talking about your current motivation to get better. What are the pros and cons of change? What does life look like in 1 year or 5 years time if you don’t recover? What does it look like if you do recover? What support systems can help you to keep going, even during periods of low motivation?

Therapy for anorexia

In the UK, the NHS recommends three main therapy types for anorexia: SSCM, CBT, and MANTRA.

Enhanced Cognitive Behavioural Therapy (CBT-E) for eating disorders helps people to recover from anorexia by addressing the links between thoughts, feelings, behaviours and bodily reactions.

There are four stages to therapy. It starts by supporting people with motivation and stabilising eating. In stage 2, we review and plan the rest of treatment. Stage 3 includes the rest of active treatment. Commonly it includes body image, emotional wellbeing, problem solving, overcoming fear foods, and addressing the eating disorder mindset. Stage 4 covers relapse prevention and planning for the future. CBT-E is typically 20-40 sessions long.

The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) integrates different models of therapy to target the key factors maintaining anorexia. This can include addressing thinking styles, emotion regulation, interpersonal relationships, self-compassion, and positive beliefs about anorexia. It is typically 20 sessions long with some additional sessions to bring loved ones in where this is helpful.

Specialist Supportive Clinical Management (SSCM) is a goal-driven approach. It is usually about 20 sessions long and the topics covered will vary depending on what you want to get out of it. Your goal might be to reach a healthy weight, but it might also be to stop feeling cold all the time, or to be able to have a family, or go to uni. Emphasis is placed on building a strong therapeutic relationship and improving nutritional status and quality of life.

Most people will be able to recover from anorexia at home. Some people with anorexia will need inpatient care to stabilise physical health, particularly if someone’s BMI has reached a critically low point. The MEED guidelines provide more detail about assessing physical health. You might also need an inpatient stay if you have tried recovering at home but need more intensive support to make changes.

Finding a therapist

In the UK, you can find an eating disorder therapist via the NHS or privately. Each area of the UK will have a specialist NHS eating disorder team which your GP can refer you to.

It’s important to find a therapist who is knowledgeable on eating disorders and one that you feel you can build a good relationship with. I have written a full guide on how to find a good eating disorder therapist.

Weight

Restoring weight

One of the biggest criticisms of eating disorder services is that people are too focused on weight. And there is some truth in this. Many people I’ve worked with can tell stories of professionals who appeared to only care about the number on the scales.

On the other hand, if you go to see a therapist and there is no talk about weight at all, it is very unlikely to help you get better.

So why do eating disorder therapists care so much about weight? Because malnourishment, whether due to being underweight or under-eating, significantly changes people’s thinking patterns, worsens mood, heightens preoccupation with food, and disrupts the ability to recognise hunger cues. These factors make it impossible to recover from an eating disorder whilst being malnourished.

Therapy for anorexia often makes people feel worse before they feel better. This stems from facing fears about food and weight head-on. Nutritional rehabilitation gives you the best possible foundation to address emotional links, improve body image, and build self-compassion.

For outpatient treatment, the recommendations is to aim for restoring about 0.5kg per week. This rate strikes a balance between being steady enough avoid overwhelming while also not prolonging the distressing process of weight restoration unnecessarily.

Target weights

But how much weight should you aim to gain? Eating disorder therapists typically advise reaching a BMI of around 20 as a minimum target.

The NHS BMI chart will tell you that a BMI of 18.5 to 25 is within the healthy range. For some people a BMI of below 20 will be healthy. However, the problem is that BMI is based on population level data. Meaning that some people naturally sit at a BMI of 18.5 and be healthy.

This does not mean that a BMI of 18.5 will be healthy for everyone. Far from it. In reality, only a very tiny percentage of the population will naturally sit this low.

To kick anorexia out of your life you will eventually need to be able to eat when you’re hungry and stop when you’re full (although at first you will probably need to eat to the clock, more on this below). Your body will have it’s own natural set-point in weight.

If you try to keep your body weight artificially lower than it’s natural set-point, your body will give you hunger signals, make you think about food, and leave you prone to binging.

The reason eating disorder therapists suggest a minimum BMI of about 20 is because most people’s natural set point will be 20 or higher. Once people reach this point we see definite improvements in the psychological symptoms of being malnourished.

Weekly weighing

It’s recommend that you weigh yourself once a week during eating disorder recovery. This frequency gives you to have enough information to know what is happening with your weight and helps you challenge any fears related to weight gain without overly fixating on the numbers. 

It’s important to look at trends over time rather than focusing on individual weigh-ins. Various factors such as hydration levels, hormonal fluctuations, and the time of day can influence the number you see on the scales. Because of this, you should wait until 4 weeks have passed before you try to interpret any trends in your weight.

In the long-run, aim to transition to weighing themselves occasionally and not avoid weighing entirely. Avoidance tends to increase anxiety, so occasional monitoring can help maintain a healthy relationship with weight.

Food in anorexia recovery

Regular eating

If you have been severely restricting your eating, or if your BMI is very low (below 18.5), you may be at risk of re-feeding syndrome. Re-feeding syndrome is a serious medical complication that can lead to death in some circumstances. It is very important that you consult a medical professional before increasing your food intake.

Now that we have the rationale for restoring weight, let’s discuss how to approach this in a way that feels manageable.

The first step in therapy is establishing regular eating. Many people with anorexia will delay their eating or eat at irregular times.

When in recovery from anorexia it’s important to eat every 3-4 hours (except overnight). This is because after this time period our blood sugar will drop, triggering hunger signals and increased thoughts about food.

If you’ve been restricting you’re eating for a while you might have stopped experiencing hunger in the normal way. Therefore, Ii’s important not to rely on physical hunger cues in the initial stages of recovery.  

Before increasing portion sizes, we focus on implementing eating at regular intervals. Here is a breakdown of meals and snacks with example times:

7am Breakfast
10am Morning snack
1pm Lunch
4pm Afternoon snack
7pm Dinner
9pm Evening snack

Once you are in the rhythm of regular eating, we then gradually increase portion sizes. You probably have lots of foods that you avoid. At this early stage we prioritise increasing energy intake before tackling feared foods.

Meal planning

Some people find that meal planning helps them stick to regular eating in the beginning stages. I’ve listed some useful resources for meal planning below:

CBT-T example meal plans

CCI eating for recovery

FREED food guidelines

NHS under 18 example meal plans

Monitoring

Monitoring is a commonly used tool in Cognitive Behavioural Therapy (CBT) for eating disorders. Monitoring (sometimes called food diaries) involves keeping a log of the foods you eat, when and where you eat them, and the thoughts and feelings you experience.

The purpose of monitoring your food is to get an accurate representation of your pattern of eating, learn how your eating disorder is connected with your thoughts and feelings, and to help you learn from setbacks.  

You can use paper monitoring sheets, a dedicated app, or simply the notes section in your phone.

The key is that you record in real-time. This is because human memory is notoriously unreliable. You might be able to remember everything you ate yesterday, but can you remember your thoughts and feelings in detail?

Some people may initially find food monitoring distressing. Seeing a day’s worth of food written down can be confronting, especially if you’re not used to it.

Anorexia might try to convince you that you’re eating too much. Look back at your weekly weights. Is anorexia telling you the truth? What has actually happened to your weight over the past 4 weeks?

The discomfort at using monitoring sheets should subside in a few weeks. If it doesn’t, there are other therapeutic approaches to try. For example, you could speak to your therapist about MANTRA therapy.

One key point to remember is to not use monitoring sheets to record calories. This will increase your preoccupation with food and is not the purpose of food monitoring.  

Rules / safe foods

Once you are eating enough, we can begin addressing food rules and fear foods. If you’re struggling with anorexia, you probably have a number of rules about foods. You probably also have lots of foods that you avoid.

Examples of food rules are:

  • Not eating before a certain time of day
  • Avoiding carbs
  • Avoiding “junk” foods
  • Eating less than people around you
  • Cooking with water or sprays rather than oils.

Most people find that they’ve adopted lots of rules and may not even be consciously aware anymore that some of their eating choices are driven by anorexia.

Over time, fears associated with consuming these foods or breaking a food rule tends to intensify. Maybe you fear that if you eat bread, you will gain weight uncontrollably? Or maybe you’re scared that if you have some dessert, you won’t be able to stop eating and will binge?

Each week, try to test out some of these fears. For example, you could decide that for the next week you will eat “treat” food for one snack a day. Write down what you predict will happen. For example “I will gain 3 kilos in a week”. At the end of the week, reflect on what the outcome was. Did your prediction come true? Remember that we can’t interpret trends in weight for 4 weeks.

Exercise

Although exercise can be a healthy part of every-day life, it can become problematic for people with anorexia. If you find yourself feeling compelled to exercise or experience intense guilt when unable to do so, it’s important to improve your relationship with physical activity.

The NHS physical activity guidelines recommends that adults aim to do strength-based activities 2 days a week, plus either 150 minutes of moderate exercise or 75 minutes of vigorous exercise per week.

However, it’s essential to adapt these guidelines based on your stage of recovery. If you’re your physical health is not stable, if you have a very low BMI, or if you have needed hospital treatment, then you should speak to your healthcare professional who can advise you on what exercise level is safe for you.

Even if your physical health is stable, you may need to reduce your exercise level temporarily if you are struggling to eat enough food to restore weight.

Exercise may have become all about weight and body shape. But there are many other positives about exercise. It keeps our body healthy, prevents disease, improves mental health and if you find the right activity, it is fun!

Think back to activities you enjoyed before developing anorexia. When did you enjoy moving your body? Did you have a favourite sport? If nothing springs to mind, try experimenting with new sports or exercise that you might enjoy. Many people find joy in activities that connect them with nature.

If you have a history of compulsive exercise I recommend starting with something with a defined beginning and end. This could be a group sport session, or dance class. Or something with a friend where you leave together.

Whilst your exercising check in with yourself. Are you enjoying yourself? Do you feel like you have to carry on. Are you at risk of getting injured? Have you had enough rest time? Take a step back, or change activity, if these questions raise red flags.

Body image

Body image difficulties are very common for people struggling with anorexia. Picture body image as a spectrum, ranging from hating your body to loving your body. Initially, aiming for a neutral relationship with your body is a manageable goal.

Do you remember how you thought of your body as a child? How much attention did you give your physical appearance? Were you able to enjoy what your body could do for you, like running, playing, jumping?

When we have poor body image, physical appearance becomes extremely important to us. The first step is to start to expand other areas of our lives. What matters most to you? Have you neglected these areas since anorexia took hold? Start by trying to reintroduce activities that bring you closer to your core values. Examples might include:

  • Family
  • Career
  • Study
  • Friends
  • Hobbies

People tend to change their behaviour when they struggle with body image. The two most common changes are body avoidance and body checking.

Body avoidance includes all behaviours to avoid your body. For example, wearing baggy clothes, avoiding swimming, standing at the back of photos, avoiding mirrors. Body avoidance tends to increase problems with body image because we tend to imagine our bodies are bigger than they are. It also limits our social interactions and intensifies the focus on appearance.

Body checking involves habitual actions like mirror checking, measuring body parts, and checking how clothes fit. Body checking increases problems with body image because it focuses our attention on our appearance without offering long-term reassurance.

To improve body image, we need to reduce both body checking and body avoidance.

Emotions

Many people with anorexia have difficulties with emotions. This might be difficulty identifying emotions, managing intense emotions, or expressing emotions to others.

It’s common for people with anorexia to use food restriction to try and push away their emotions. The problem with this is that, whilst you can do this in the short term, it’s almost impossible to keep emotions suppressed forever. Then when emotions do come up, they tend to come up more strongly be very overwhelming.

Identifying emotions

Emotions can be broadly categorised into pleasant and unpleasant. Within this, humans tend to experience six main emotions: happiness, sadness, anger, fear, disgust and surprise.

Within these main categories there are also many more nuanced emotions (e.g., guilt, grief, excitement). Emotions are generally expressed with one word (e.g., scared) whereas thoughts are generally sentences (e.g., that dog is going to bite me).

To reconnect with emotions, start by thinking about how your body feels when you are happy, sad, angry, scared, disgusted and surprised. What type of thoughts do you tend to experience? How do you tend to act when you are feeling each emotion?

Emotions exist for a reason. When they are working as intended, they can motivate us, tell us what we need, and protect us. For example, feeling scared when a car heads towards us will motivate us to run back to the pavement. Or if we feel lonely, it lets us know that we need more meaningful connection with others.

Take some time to re-connect with your emotions. What emotion are you feeling? What might this emotion be telling you?

Managing emotions

Dealing with intense and overwhelming emotions can be incredibly difficult to manage. It’s during these moments that people often turn to the eating disorder to cope. Other tricky coping strategies people might use include drinking excessively, self-harm, smoking, excessive social media use.

The more we try to suppress our emotions, the more intensely we will experience them when they do surface. In the long run, tuning into our emotions and expressing them with loved ones will help regulate our emotions.

In the short-term, we may need specific strategies to manage overwhelming emotions. Distraction and soothing techniques can be particularly helpful. Distractions should be captivating and readily accessible. What can your absorb yourself in? Try putting together a toolbox of easy to grab distractions.

Soothing activities help us to feel calm, secure and restful. Tapping into your senses is often the easiest way to do this. What textures feel comforting to you? Do you have a favourite warm drink? Do you have a particular candle or smell that reminds you of warm memories?

Expressing emotions

It’s also common for people to find it challenging to communicate their emotions to others. At times, it can feel easier to show people we are hurting through our body. Even if this is not our intention, sometimes it can become an unintentional pattern with loved ones.

Talking about our feelings also helps to give us distance from our thoughts and feelings and gives us a sense of perspective and connection. Grab some paper and brainstorm some people in your life that you could express your feelings with. Who is most likely to be supportive?

Sometimes the hardest bit is starting the conversation. Could you plan a regular time for a check in with this person? Can you let them know you are working on expressing yourself so they can support you with this?

Self-compassion

Are you your own worst critic? Do you tend to berate yourself when things go wrong? Or do you feel like you are never good enough? A key part of managing our emotions is developing self-compassion.

We all have an inner critic, but some people’s critic is much louder and stronger than others. How large is your critical voice? What does it say to you? How do you feel when your critic says these things? How do you act when it criticises you?

Sometimes people are doubtful about developing more self-compassion. People often worry that this will make them weak, or maybe even that they deserve to be treated badly. If this is the case, start by thinking pragmatically. Does the critic serve you? Does it help you change for the better? Or does it make you feel bad and less likely to make positive changes?

A simple way to start developing self-compassion is by using a three-step approach:

  1. Observe your feelings e.g., “I’m feeling really lonely”
  2. Validate your feelings e.g., “anyone in my position would feel this way, anorexia has taken so many opportunities away from me”
  3. Take action to look after yourself with kindness e.g. “I’m going to reach out to my friend and arrange a movie night”

Relationships

Sometimes the people in our life can intentionally or unintentionally keep anorexia going. The animal metaphors describe how our loved ones can respond.

Ideally, we want our loved ones to respond with compassion and loving boundaries. It’s important to say that even in the most loving and caring relationships it is impossible to respond perfectly every time. But do the people around you respond in supportive ways more often than not?

Do you notice patterns that keep anorexia going?

Sometimes a loved one finds anorexia so upsetting that they are unable to provide containment. Other times people may be so scared by anorexia that they respond with anger and attempt to force their loved one to change. Or sometimes people feel unable to put boundaries in place regarding eating and unintentionally reinforce the problem by accommodating anorexia.

There are resources for loved ones to help notice their patterns and groups that bring together parents / family of someone who has an eating disorder. Learning more about how anorexia works and how to help is usually enough for most loved ones to make positive changes that will support you in recovery.

For some people they may have figures in their life who are actively seeking to make them feel worse or undermine them. If you suspect you might be a victim of abusive behaviour it is important to seek help as soon as possible.

Thinking style

Thinking styles describe the way that you think rather than the specific thoughts you experience. For example, many people with anorexia find they tend to be quite detail orientated rather than focusing on the big picture.

No thinking style is better or worse than another. But you might find that whilst a certain thinking style benefits you in one area it might create problems in others.

For example, being detail orientated may be very useful in work such as data analysis or proofreading. But might trip you up if it means you are more likely to get tangled up in details about the nutritional content of food.

Other thinking styles that are common in people with anorexia is a tendency towards perfectionism and rigidity. Perfectionist traits include having very high standards for yourself which are almost impossible to meet.

If you struggle to be flexible in your thinking style you might notice you find changes of plan stressful, prefer to stick to routine, or struggle to see other people’s perspective. Practicing flexibility in thinking can be beneficial as life can be unpredictable and we don’t want this to cause unmanageable stress.

Knowing we have a preference for order and routine can also be helpful, as we can tailor our recovery around it (e.g., create familiar routines around meal times).  

Relapse prevention

Recovering from anorexia will include ups and downs and sometimes it includes a period of ‘quasi recovery‘. It’s important that we put together a plan so that we can deal with setbacks effectively, learn from them, and get back on track.

Your relapse prevention plan should include the things that are more likely to trip you up. For example: Are you moving to university soon? Planning on getting pregnant? Are you in problematic debt?

Next the plan should include your warning signs. Ideas to include could be:

  • Increasing preoccupation with food
  • Cutting out “junk” foods
  • Avoiding social events
  • Weighing self frequently
  • Weight loss

Lastly, your plan should describe the steps you will take. For example:

  • Opening up to a trusted person
  • Reintroducing “fear foods”
  • Practice self-compassion
  • Revisit meal plan and increase portion sizes
  • Remove weighing scales
  • Speak to GP or reach out to a professional

References

Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press.

Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: toward an integrative model of change. Journal of consulting and clinical psychology51(3), 390.

Schmidt, U., Startup, H., & Treasure, J. (2018). A cognitive-interpersonal therapy workbook for treating anorexia nervosa: the Maudsley model. Routledge.

Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V., & Russell, K. (2007). Cognitive behavioral therapy for eating disorders: A comprehensive treatment guide. Cambridge University Press.


If you are looking for a therapist to recover from anorexia, and you think we might be a good fit, book a free consultation here.

About

Welcome. I'm Dr Jenny Davis, a Clinical Psychologist with a special interest in eating disorders. I'm passionate about helping people recover and build a healthy relationship with food. 

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