The House Always Wins
I hate gambling. The few times I've ever been to a casino, I didn’t particularly enjoy playing the slots, and stopped after my $40 limit ran out because, as we all have been told, the house always wins. Yet I remain optimistic that someday I might win the lottery and retire to my fantasy house on the beach. Hope springs eternal
I liken this to your eating disorder. Your eating disorder will always win—if you feed it your hard-earned currency. Meaning any time you decide to play the game, you can’t beat it. Even if you try to set limits.
Can you recover from an eating disorder? Absolutely 100%. But can you outsmart one? Live with just “a little” of it? No. Because your eating disorder is insidious, and it is as sneaky as the one-armed bandit—aka the slot machine.
“Trust Me, I’m Fine”
A patient of mine—who has been weight restored for years—recently lost weight due to a medication change. She slowly continued to lose, and soon fell below her weight range. I raised my concerns, telling her, "The (eating disorder) ED is still present. You can't maintain this current weight and stay recovered."Her response was…
Trust me.
I am eating just fine and I am not having disordered thoughts.
I like my body now for the first time in a long time.
I can remain at this weight and not relapse.
I had a distinct feeling of unease. I sounded the alarms and I contacted the rest of her team. We were all highly troubled, and yet she was saying…
Nope.
I'm eating.
I'm fine.
And you all are being crazy.
In discussion, I said to her “I am not accusing you of being dishonest, it's your ED. I've been doing this a long time and have learned that you cannot beat the system. The house always wins.”
She gave me a dirty look.
So how do I know it is so vitally important to maintain your weight and how even a small loss can push someone towards a relapse? Science. Specifically, biology.
The Odds Are Not in Your Favor
I frequently refer to the excellent article: When in Doubt, Aim Higher: What I Wish I’d Known About Target Weights in Recovery - F.E.A.S.T. In it, the author cites: It is impossible to achieve full recovery if one's weight is too low for their body. She further explains that when someone is in a calorie deficit, it becomes difficult to trust their body's hunger signals. For individuals with an eating disorder, both the biological cues and mental distortions can feel familiar and comforting while the prospect of regaining weight—even if they know it's necessary—can be frightening.
According to researcher Cynthia Bulik: Negative energy balance, i.e. taking in less energy than the body needs, doesn’t affect everyone the same way. For people who are in recovery from an eating disorder, it in fact often feels profoundly different. For these individuals, the early stages of under-eating can produce a sense of calm. In clinical terms, it’s anxiolytic—it reduces anxiety.Which means the allure of restriction isn’t just about body image, it’s about relief.
This is a huge reason why the patterns of restriction can become self-reinforcing. If eating less quiets an otherwise stressed or overwhelmed system, the behavior serves a purpose beyond the impact on body shape and size. Over time, that link between undernourishment and emotional regulation can become deeply ingrained. This is a biological response. This is the science I was talking about. And this is one of the reasons why recovering from an eating disorder is so challenging. This altered response to the negative energy balance also helps to explain both the onset of the disorder, and the risk of relapse. If even minor restriction brings a familiar sense of relief—no matter how subtle—this can open the door to relapse and a world of pain.
You Can’t Beat the House, But You Can Walk Away
What is happening to your body matters too, though. It doesn’t matter if it's a new medication, a week with the flu, or an appetite temporarily disrupted by grief. Weight suppression is defined as the difference between a person’s weight before their eating disorder and their current weight, and research indicates that high weight suppression is associated with the persistence of an eating disorder.
This is why gaming the house never works. To maintain your lower weight (a suppressed weight) your lifestyle must include behaviors which are in contradiction of healing. You will lose your shirt to the house—and your footing in recovery. My patient later admitted that yes, she had been gambling with her recovery. Now she faces the hard climb back toward wellness, and it is truly my hope that she never lets the house win again.
My hope for her is eternal.