anorexia nervosa latest research

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Key searches, groundbreaking study shows substantial differences in brain structure in people with anorexia.

New findings from the largest study to date by an international group of neuroscience experts show significant reductions in grey matter in people with anorexia nervosa.

Eating disorders are often misunderstood as lifestyle choices gone awry or oversimplified as the unfortunate result of societal pressures. These misconceptions obscure the fact that eating disorders are serious and potentially fatal mental illnesses that can be treated effectively with early intervention. Mortality rates for people with eating disorders are high compared to other mental illnesses, particularly for those with anorexia nervosa, a condition characterized by a severe restriction of food intake and an abnormally low body weight. People with anorexia can literally starve themselves, causing severe and potentially fatal medical complications. The second leading cause of death for people with anorexia is suicide.

Now, a groundbreaking new study by a global team of researchers led by the Keck School of Medicine of USC’s Mark and Mary Stevens Neuroimaging and Informatics Institute ( Stevens INI )  has revealed that individuals with anorexia demonstrate notable reductions in three critical measures of the brain: cortical thickness, subcortical volumes, and cortical surface area. These reductions are between two and four times larger than the abnormalities in brain size and shape of individuals with other mental illnesses. Reductions in brain size are particularly concerning, as they may imply the destruction of brain cells or the connections between them.

Equipped with these results, the research team is calling attention to the pressing need for prompt treatment to help people with anorexia avoid long-term, structural brain changes, which could lead to a variety of additional medical issues. Anorexia can be successfully treated with healthy weight gain and cognitive behavioral therapy. Ongoing work by the same group shows that successful treatment can have a positive impact on brain structure.

“By comparing nearly 2,000 pre-existing brain scans for people with anorexia, people in recovery and healthy controls, we found that for people in recovery from anorexia, reductions in brain structure were less severe,” says Paul M. Thompson, PhD , associate director of the Stevens INI. “This implies that early treatment and support can help the brain to repair itself.”

In addition to researchers from the Stevens INI, the research team includes neuroscientists from the Technical University in Dresden, Germany; the Icahn School of Medicine at Mount Sinai, New York; University of Bath, UK; and King’s College London. The researchers came together under the ENIGMA Eating Disorders working group ( ENIGMA-ED ), a part of the  ENIGMA Consortium , co-founded and led by Thompson. ENIGMA is an international effort to bring together researchers in imaging genomics, neurology, and psychiatry, to understand the link between brain structure, function and mental health.

Through advances in neuroimaging, researchers are gaining a better understanding of the link between serious mental health disorders and brain abnormalities. By demonstrating the effects of anorexia on brain structure, ENIGMA-ED has underscored the severity of the condition and the need for early intervention, while paving the way for the development of more effective treatments.

“The international scale of this work is extraordinary. Because scientists from twenty-two centers worldwide pooled their brain scans together, we were able to create the most detailed picture to date of how anorexia affects the brain, “says Thompson, professor of ophthalmology, neurology, psychiatry and the behavioral sciences, radiology, pediatrics and engineering. “The brain changes in anorexia were more severe than in any other psychiatric condition we have studied. Effects of treatments and interventions can now be evaluated, using these new brain maps as a reference.”

“This study exemplifies why the work at the Stevens INI is so essential,” says INI Director and longtime colleague of Thompson, Arthur W. Toga , PhD. “The goal of the ENIGMA Consortium is to bring researchers together from around the world so that we can combine existing data samples and really improve our power to examine the brain and detect the subtle brain alterations associated with a given illness. At the Stevens INI we apply this goal to all our large-scale studies. We are committed to participating in large studies with diverse research cohorts and sharing data to advance the entire scientific community.”

About ENIGMA ED

ENIGMA-ED is dedicated to improving our understanding of structural brain changes in patients with anorexia nervosa and bulimia nervosa and how those changes normalize during or after recovery. This group aims to conduct a meta-analysis of existing MRI data with adolescents and adults who have or had an eating disorder in the past. ENIGMA-ED welcomes new cohorts. For more information on how to join and contribute anorexia nervosa data, contact Dr. Stefan Ehrlich ( [email protected] ). To join and contribute bulimia nervosa data, contact Dr. Laura Berner ( [email protected] ).

Several researchers at the Stevens INI have also partnered with Stuart Murray , director of the Eating Disorders Program at the Keck School of Medicine of USC to study binge eating disorder in young children . See their most recent findings here and here .

Access the full study  ‘Brain Structure in Acutely Underweight and Partially Weight-Restored Individuals with Anorexia Nervosa – A Coordinated Analysis by the ENIGMA Eating Disorders Working Group’  published in the Journal Biological Psychiatry . Other USC co-authors contributing to the study include Neda Jahanshad, PhD, associate professor of neurology and biomedical engineering, and Sophia Thomopoulos, BS, consortium manager for the ENIGMA study.

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New Research Aims to Elucidate Neurobiology of Anorexia Nervosa

Studies in animal models help scientists identify systems that may induce vulnerability to eating disorders, and aid in pinpointing brain consequences of behaviors that underpin anorexia nervosa.

For nearly a dozen years, psychiatry researchers at Johns Hopkins have been studying behavioral and neurological changes related to anorexia using the activity-based anorexia, or ABA, model in young female rats. Some lessons learned in these animals are being applied to clinical research in search of better understanding and management of the condition for patients.

There is a dearth of information about the neurobiology of anorexia, which can make treatment challenging, says  Kimberly Smith , assistant professor of psychiatry and behavioral sciences: “Using the ABA model, we can begin to shed light on that underlying neurobiology and can answer questions such as: Does anorexia change neural circuitry? Does it change physiology? What’s going on in the brain or in the body that may maintain the disorder? Through such inquiries, we may begin to identify treatment targets.”

The ABA model gives rats free access to a running wheel and restricted time for food intake. Studies over the years have indicated that rats exposed to the program can rapidly acquire alterations in taste and restricted food preferences, increased anxiety and lower circulating levels of some antioxidants, among other changes, says  Timothy Moran , director of Johns Hopkins’ Behavioral Neurosciences Laboratory.

The work “has helped identify brain systems that might induce a vulnerability to eating disorders, Moran says, “and it has identified brain consequences of engaging in the kind of behaviors that underlie anorexia nervosa.”

One study directed by psychiatry researcher  Kellie Tamashiro  and Angela Guarda, director of the Johns Hopkins Eating Disorders Program, is looking at levels of an appetite-stimulating peptide called agouti-related peptide, also known as AgRP, in patients with anorexia. Previous work by Tamashiro’s lab demonstrated that rats who passively reacted to stress induced by the ABA model had less AgRP and were more vulnerable to weight loss. The current study compares circulating levels of AgRP in the blood of patients with anorexia at the time of hospital admission and again after their weight has been restored. The researchers will look at hypothalamic regions of the brain controlling hunger using MRI to identify if the hormone is associated with greater disease severity.

“This could be the first clear identification of something that might not be simply a response to anorexia nervosa, but may be a predisposing factor,” says Moran, a coinvestigator.

Building on that work, Smith, another coinvestigator, has started her own study funded by the National Institute of Mental Health to compare eating-related anxiety in people with and without anorexia, and if that changes following treatment. The work includes using functional MRI to identify any underlying brain differences when participants are shown pictures of high calorie-density foods such as a donut or low calorie-density foods such as strawberries, and asked how comfortable they would be eating those items. Results in the first few patients indicate that anxiety is lessened after meal-based behavioral treatment, when patients are restored to a healthy weight.

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Inpatient treatments for adults with anorexia nervosa: a systematic review of literature

• Open access
• Published: 20 May 2024
• Volume 29 , article number  38 , ( 2024 )

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• Federica Toppino   ORCID: orcid.org/0000-0003-1524-1272 1 ,
• Matteo Martini   ORCID: orcid.org/0000-0001-8877-0138 1 ,
• Paola Longo   ORCID: orcid.org/0000-0003-1347-7054 1 ,
• Inês Caldas 2 ,
• Nadia Delsedime   ORCID: orcid.org/0000-0002-3564-598X 1 ,
• Raffaele Lavalle   ORCID: orcid.org/0009-0008-6213-8378 1 ,
• Francesco Raimondi 1 ,
• Giovanni Abbate-Daga   ORCID: orcid.org/0000-0002-5826-5664 1 &
• Matteo Panero   ORCID: orcid.org/0000-0002-9385-0332 1  

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Anorexia nervosa (AN) is a mental disorder for which hospitalization is frequently needed in case of severe medical and psychiatric consequences. We aim to describe the state-of-the-art inpatient treatment of AN in real-world reports.

A systematic review of the literature on the major medical databases, spanning from January 2011 to October 2023, was performed, using the keywords: “inpatient”, “hospitalization” and “anorexia nervosa”. Studies on pediatric populations and inpatients in residential facilities were excluded.

Twenty-seven studies (3501 subjects) were included, and nine themes related to the primary challenges faced in hospitalization settings were selected. About 81.48% of the studies detailed the clinical team, 51.85% cited the use of a psychotherapeutic model, 25.93% addressed motivation, 100% specified the treatment setting, 66.67% detailed nutrition and refeeding, 22.22% cited pharmacological therapy, 40.74% described admission or discharge criteria and 14.81% follow-up, and 51.85% used tests for assessment of the AN or psychopathology. Despite the factors defined by international guidelines, the data were not homogeneous and not adequately defined on admission/discharge criteria, pharmacological therapy, and motivation, while more comprehensive details were available for treatment settings, refeeding protocols, and psychometric assessments.

Though the heterogeneity among the included studies was considered, the existence of sparse criteria, objectives, and treatment modalities emerged, outlining a sometimes ambiguous report of hospitalization practices. Future studies must aim for a more comprehensive description of treatment approaches. This will enable uniform depictions of inpatient treatment, facilitating comparisons across different studies and establishing guidelines more grounded in scientific evidence.

Level of evidence

Level I, systematic review.

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Introduction

Anorexia nervosa (AN) is a severe mental disorder characterized by an intense fear of gaining weight and a distorted body image. Individuals with AN exhibit severe dietary restrictions or engage in other weight loss behaviors such as excessive physical activity or purging, resulting in low body weight. The medical complications of AN affect various organs and systems and are accompanied by impairments in cognitive and emotional functioning [ 1 , 2 ]. These severe symptoms often require intensive treatments such as hospitalization, partial hospitalization, and intensive ambulatory settings [ 3 ].

Inpatient treatment represents the highest level of care, especially for medically or mentally unstable patients or those unresponsive to outpatient care. AN is the eating disorder (ED) with the highest hospitalization rate, accounting for 32% of patients [ 4 ]. Intensive treatment in a hospital setting is usually determined by a set of clinical indicators [ 5 ]. Despite efforts with outpatient therapies, an increase in admission rates has been reported in several Western countries due to the inherent severity of the disease or resistance to outpatient care [ 6 , 7 , 8 ]. Weight gain is central to the treatment, with clinicians prescribing caloric intake while monitoring malnourished patients closely. Patient motivation is crucial, and psychological interventions during inpatient care aim to encourage the patient's willingness to change [ 1 ].

Several international guidelines, such as those from the World Federation of Societies of Biological Psychiatry (WFSBP) [ 9 ], National Institute for Health and Clinical Excellence (NICE) [ 10 ], Medical Emergencies in Eating Disorders (MEED) [ 11 ], and Royal Australian and New Zealand College of Psychiatrists Clinical Practice (RANZCP) [ 12 ], outline situations where hospitalization is appropriate. However, the criteria are not rigid and there is also room for the importance of clinical expertise and personalized therapy. Furthermore, there are some distinct national guidelines for the treatment of AN, such as a Spanish one from 2009 [ 13 ], a French one from 2010 [ 14 ], and a German one revised in 2018 [ 15 ]. One of the most recent is from the American Psychiatric Association (APA) and was published in February 2023 [ 16 ].

According to these guidelines, outpatient treatment is considered the first-line therapy setting for AN patients. Criteria for more intensive care levels, such as full-time hospitalization, are also included. All guidelines highlight the importance of deciding on hospitalization based on individual factors that are to be considered for patients who have not responded to outpatient care or are at high risk for medical complications, such as extremely low body mass index (BMI), behavioral aspects, vital signs, psychiatric comorbidity, and environmental aspects [ 16 ]. While a BMI below 15 kg/m2 in adults or < 70% median BMI in children defines extreme malnourishment, it is stressed that BMI alone is not the sole criterion for hospitalization.

Effective AN treatment involves a multidisciplinary team, typically including psychiatrists, dieticians, nurses, psychologists, and internal medicine physicians [ 1 , 16 , 17 ]. Differences in international guidelines highlight the varying compositions and emphases of such teams: APA [ 16 ] and WFSBP [ 9 ] focus on extensive medical monitoring, while NICE [ 10 ] includes occupational therapists and social workers.

The core aspect of inpatient treatment is nutritional rehabilitation, focused on weight gain through personalized dietary plans and refeeding practices. Guidelines consistently favor oral enteral nutrition over parenteral nutrition, which should only be used as a last resort [ 16 , 18 ]. Concerning weight gain, while lacking standardized protocols, there is some consensus on weight gain of 0.5–1.4 kg/week during hospitalization [ 12 , 13 , 14 , 16 ]. Despite variations in starting caloric prescriptions, personalized dietary plans are recommended; some guidelines provide specific recommendations regarding supplementation [ 12 , 13 , 16 ], while others suggest a general vitamin supplement [ 10 ]. Furthermore, supplementary treatment suggestions were provided, such as meal support and supervised physical activity [ 16 ]. One guideline expressly advised against the use of physical therapies, including electroconvulsive therapy and transcranial magnetic stimulation [ 10 ].

While psychotherapy stands out as a crucial component of treatment, only a few guidelines have recommended specific interventions during hospitalization. Notably, Cognitive-Behavioral Therapy (CBT) is endorsed by several guidelines [ 10 , 12 , 13 , 16 ], followed by Family-Based Treatment (FBT). Psychodynamic Psychotherapy and Interpersonal Psychotherapy are mentioned but with less unanimous support [ 16 ]. Novel treatments addressing emotional difficulties are under study. Motivation to change is central and should be assessed in a transtheoretical model and with motivational interviewing. MEED guidelines also address work on the lack of insight and tendency to sabotage, emphasizing the importance of individual contracts with patients [ 11 ]. RANZCP underlines the role of family therapy [ 12 ].

Regarding medication, three guidelines [ 10 , 12 , 13 ] emphasize that it should not be the primary treatment. Almost all guidelines recommend fluoxetine as the preferred selective serotonin reuptake inhibitor (SSRI) [ 9 , 12 , 13 , 16 ], either alone or in combination with psychotherapy [ 16 ], or fluvoxamine [ 9 ]. However, one guideline [ 15 ] discourages the use of antidepressants for weight gain.

The transition from inpatient to outpatient care is crucial for AN, with care plans specifying discharge and reintegration into community-based care [ 10 , 19 ]. The end of inpatient treatment often results in care discontinuity, stressing the need for a smoother transition, supported by psychological interventions [ 20 ]. International guidelines vary in their follow-up recommendations: APA [ 16 ] and WFSBP [ 9 ] suggest regular and gradually tapering follow-up sessions, NICE [ 10 ] advocates for a named professional to coordinate comprehensive care plans, RANZCP [ 12 ] emphasizes early planning for discharge and continuous psychotherapy.

The present study aims to review the current scientific literature about hospitalization in AN, analyzing both the adherence to established guidelines and cases in which real-world practices differ from standards of treatment. We encountered a general paucity of comprehensive reviews on hospitalization, except for a previous work conducted by Suárez-Pinilla and colleagues in 2015 [ 21 ], which focused on treatment (especially psychopharmacology). Although the review has the merit of underlining some key aspects of the treatment, it is dated, considers only the randomized controlled trial (RCT) studies, does not specifically analyze the adult population, and does not consider some crucial factors of hospitalization. Unlike the paper from 2015, we aim to cover a broader examination, encompassing other aspects of inpatient treatment and including a more diverse set of studies. Additionally, our scope is to incorporate the most recent literature, extending from 2013 onwards.

Our intention is therefore to cover through the method of the systematic review a wide range of aspects related to hospitalization, addressing a gap in the current scientific literature and recognizing that it is not uncommon to venture beyond established guidelines in psychiatry. Our objective is to highlight the distinctions between routine treatment decisions and their corresponding established protocols. Despite the availability of treatment guidelines, there is no universally defined type A hospital treatment. Inpatient treatment is the preferred setting when other forms of outpatient care (e.g., ambulatory, day hospital) prove insufficient. In cases where AN reaches a severe stage, posing a threat to a patient's life, it becomes crucial to provide a secure environment for a comprehensive treatment.

The following systematic review adheres to the criteria outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses—Extension for Scoping Reviews PRISMA-ScR statement [ 22 ]. The search spanned from June to October 2023 and encompassed databases such as PubMed, PsycInfo, Embase, and Cochrane Central Register of Controlled Trials. The search strategy involved the combined use of the terms “inpatient” OR “hospitalization” AND “anorexia nervosa”. The PRISMA checklist, the PRISMA checklist for abstracts, and the flow diagram of the studies included are available from Supplementary Materials.

The included papers adhere to the following criteria: (a) studies published between 2011 and October 2023; (b) studies investigating inpatient treatment in hospitals for AN (regardless of the type); (c) studies published in English. Single case studies, reviews, and studies on pediatric populations were excluded. Additionally, studies related to inpatient treatment in residential facilities were excluded. Neither the gender nor nationality of participants nor the absence of healthy controls served as exclusion criteria. In addition to keyword searching, we used citation chaining in full-text screening to intercept content that the original searches may have missed. The authors F.T., I.C., and M.P. individually conducted the assessments and later discussed any discrepancies regarding the articles and inclusion criteria. Out of the initial 846 studies identified, 105 were chosen for full-text review. Among these, 49 were excluded due to their predominant focus on pediatric populations [ 23 , 24 ], 21 were omitted because they also pertained to non-hospitalization settings [ 25 , 26 ] and 8 were disregarded for their inclusion of a significant number of patients with various EDs [ 27 , 28 ]. Consequently, the final 27 studies were selected for this review (see Flow Diagram in Supplementary Materials). Four investigators (F.T., M.P., R.L., and F.R.) evaluated the methodological quality of the studies included using the 2018 version of the Mixed Methods Appraisal Tool (MMAT), developed by Hong and colleagues [ 29 ]. The overall agreement was 80%, and discrepancies were resolved through discussion. The list of the studies included, their characteristics and the results of the evaluation of the methodological quality are reported in Table  1 .

The authors (F.T., M.M., P.L., N.D., and M.P.) also reviewed the data to identify the primary aspects pertinent to hospitalization: ultimately, nine key themes were selected as the main outcomes, drawing from both the major factors explored in the existing literature and the methodology employed in the previous work by Suárez-Pinilla and colleagues [ 21 ]. The 2015 paper identified five treatment areas: antipsychotics, antidepressants, psychotherapy, nutrition, and "others". We retained similar themes (pharmacotherapy, psychotherapy, and nutrition) while incorporating additional areas of particular interest in the analysis of hospitalization practices (motivation, clinical team, setting, admission/discharge criteria, follow-up, and psychometric assessment). Afterward, the authors determined the percentage of studies referencing a specific theme, described the subthemes investigated in each article and identified any areas lacking sufficient coverage. Oversight and guidance for the study were provided by G.A.D.

This review comprises a selection of 27 studies, encompassing a total of 3501 patients. Data about the different populations of patients analyzed in the single studies are available in Table  1 . While not every study provided details on the gender of the patients, 97.55% of the population in 24 studies were female [ 31 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 52 , 53 , 54 , 55 , 56 ]. Employment status was reported in five studies [ 30 , 40 , 42 , 44 , 48 ], revealing that about 47.5% were students, 25.67% were employed, and 15.72% were unemployed. The average age of patients in the 26 studies that reported this information was 27.22 years [ 30 , 31 , 32 , 33 , 34 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 ] and the mean length of inpatient stay in 18 studies was 59.35 days [ 30 , 33 , 34 , 37 , 38 , 40 , 41 , 42 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 54 , 55 ]. Diagnosis subtype was specified in only 20 of the referenced studies [ 30 , 33 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 52 , 53 , 54 , 55 ], with about 57.16% corresponding to the restrictive type of AN, and 40.73% to the binge-purging type. The mean duration of the disease was 8.50 years [ 30 , 32 , 33 , 34 , 36 , 37 , 38 , 39 , 41 , 42 , 43 , 44 , 46 , 48 , 49 , 50 , 52 , 53 , 54 , 55 , 56 ]. Among the 24 studies defining BMI at admission, the mean BMI value was 14.20 [ 30 , 31 , 32 , 33 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 56 ].

In this sample of 27 studies, specific dimensions of hospitalization in AN were explored. The subsequent sections provide a detailed examination of the nine themes identified, shedding light on the clinical team, psychotherapeutic approaches, motivation factors, protocols, nutrition practices, pharmacological treatments, admission and discharge criteria, follow-up procedures, and psychometric assessments. A synthesis of the results is shown in Table  2 .

Clinical team

Out of the 27 studies, 13 cited the presence of psychiatrists [ 33 , 36 , 37 , 39 , 41 , 43 , 46 , 48 , 49 , 50 , 52 , 54 , 56 ], 11 of psychologists [ 37 , 38 , 39 , 40 , 41 , 43 , 46 , 48 , 50 , 55 , 56 ], ten of nurses [ 39 , 41 , 44 , 45 , 46 , 48 , 49 , 54 , 55 , 56 ], seven of general clinicians [ 33 , 37 , 39 , 41 , 43 , 54 , 56 ], nine of dieticians [ 37 , 39 , 41 , 42 , 44 , 46 , 48 , 49 , 56 ], four of physiotherapists [ 42 , 46 , 49 , 56 ], two of occupational therapists and social workers [ 33 , 48 ]. Only 12 studies detailed the presence of a multidisciplinary group [ 33 , 37 , 39 , 41 , 42 , 43 , 46 , 48 , 49 , 54 , 55 , 56 ].

Psychotherapeutic theoretical framework

In terms of methodology, among the studies that provided details (14 in total) [ 31 , 32 , 33 , 34 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 45 , 55 ] the majority employed Cognitive Behavioral Therapy (CBT) (six studies) [ 32 , 33 , 34 , 38 , 39 , 40 ], followed by Psychodynamic Therapy (two studies) [ 33 , 41 ]. Additional studies outlined the application of Cognitive Remediation and Emotion Skills Training [ 31 , 32 ], Cognitive Remediation Therapy [ 36 ], Cognitive Analytic Therapy and Schema Therapy [ 32 ], and incorporated components of Interpersonal Psychotherapy [ 34 ]. These methodologies were employed either independently or as adjunctive approaches. Only five studies explicitly clarified the frequency of psychological sessions, with three conducting it once or twice per week [ 38 , 40 , 43 ], one twice a week [ 34 ], and one claiming three times a week [ 41 ]. Nine of the studies incorporated therapy groups [ 32 , 34 , 36 , 38 , 40 , 41 , 43 , 45 , 55 ], and five studies involved family through meetings, education or counseling [ 32 , 33 , 39 , 41 , 45 ].

Out of the 27 studies, only seven addressed the issue of motivation [ 33 , 34 , 37 , 38 , 39 , 41 , 43 ]. Three studies utilized questionnaires, namely The Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ) [ 41 ], Overcoming Anorexia Nervosa Questionnaire (OANQ) [ 33 ] and the University Rhode Island Change Assessment Scale (URICA) [ 34 ], to assess motivation. The remaining studies generically recommended including motivation to change in the treatment and emphasized the importance of encouraging the patient. One study indicated the evaluation of motivation upon admission, wherein therapists were instructed to assess and rate it on a scale ranging from 0 to 4 [ 38 ].

Inpatient treatment protocols

Among the reviewed studies, 18 provided information on the mean duration of inpatient stay, indicating 59.35 days [ 30 , 33 , 34 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 48 , 49 , 50 , 51 , 54 , 55 ]. Two studies mentioned that the patients could be referred from the emergency room [ 39 , 46 ], while another stated that they were transferred from an intensive care unit [ 49 ]. All the studies specified the type of ward, with 19 being specialist EDs inpatient units [ 30 , 31 , 32 , 33 , 35 , 36 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 48 , 51 , 55 , 56 ], three Psychiatry units [ 34 , 47 , 52 ], two Internal Medicine units [ 37 , 50 ], one Physical Medicine and Rehabilitation unit [ 49 ], and one Nutrition unit [ 54 ]. Additionally, one study was conducted in two integrated Psychosomatic and Psychotherapeutic wards [ 53 ].

Reefeding and nutrition

Of the total of studies, 18 provided some information about refeeding practices. Regarding oral nutrition, two studies outlined three meals per day [ 40 , 43 ], two reported three meals plus two snacks [ 41 , 56 ], and other two specified three meals plus three snacks [ 39 , 44 ]. Meals were often taken in groups with assistance from nurses or dieticians during meals, according to 11 studies [ 33 , 38 , 40 , 41 , 43 , 44 , 45 , 49 , 54 , 55 , 56 ], although this was not recommended by two studies at the beginning of the treatment [ 33 , 38 ]. In case of incomplete feeding or insufficient weight gain, four studies reported administering direct supplementation with an oral or enteral hypercaloric solution [ 33 , 38 , 42 , 54 ]. One study specified the absence of direct supplementing in case of incomplete meals [ 44 ].

In the total of 27 distinct studies, ten implemented the use of a nasogastric tube (NGT) [ 33 , 37 , 38 , 41 , 42 , 44 , 46 , 47 , 49 , 52 ]. In one study NGT was utilized within the first 48 hours if the BMI was less than 13, as part of a refeeding protocol [ 46 ]. Another study reported using NGT if nutritional objectives were not met within two days [ 42 ], and yet another if there was insufficient weight gain [ 38 ]. In a different study, NGT was used by default with an intake at the entry of >1500 Kcal/day, gradually reducing by 250 Kcal per week if the weekly objective of weight gain was reached [ 49 ]. Additionally, two studies specified routine electrolyte supplementation [ 37 , 46 ].

Two studies mentioned locking toilets after meals [ 33 , 44 ], with one specifying a 2-h lock [ 44 ]. Conversely, in one study, access to toilets was free [ 40 ]. In one study, all meals were followed by supervised rest in a seated position lasting from 30 to 60 min [ 54 ]. For three of the studies, the weekly weight gain goal was 1000 g [ 44 , 47 , 56 ], while the remaining studies had varied goals, such as 700 g per week [ 38 ], one between 700 and 1000 g [ 43 ], one 1400 g week [ 45 ], one more than 500 g per week [ 49 ]. In one study, if a patient failed to achieve 2% weekly weight gain, the energy value of the menu was increased, typically by 600 kJ [ 54 ].

Only five studies specified weight monitoring twice a week [ 43 , 49 ], while another reported weight measurement once per week [ 56 ]. In another study body weight was measured daily up to day 6, then twice a week [ 37 ].

Discussing caloric intake, various studies proposed different approaches. Two studies recommended a gradual increase, starting with 50% of individual basic energy needs on day 1, reaching 100% on day 6, and adding 300 kcal every 3 days in the second week [ 42 , 44 ]. Basic energy needs were defined as 35 kcal/kg/d for adults. Another study opted for a non-hypercaloric diet (1700 kcal/day) to achieve a minimum weight compatible with health [ 39 ]. A different approach involved an initial intake of 1500 kcal/day, increasing to 2000 kcal in the second week and further to 2500 kcal from the third week onward [ 33 ]. Three studies specified final caloric intakes: one at 3500-4000 kcal/day [ 45 ], another at 3200-3400 kcal/day [ 51 ], and a third setting the maximum at 3000 kcal/day [ 52 ]. Additionally, the latter study mentioned an initial prescription of 600–1400 kcal/day, typically increased by about 200 kcal daily.

Four studies specified that physical exercise was permitted in a controlled manner, not compromising the efficiency of intensive refeeding [ 33 , 43 , 49 , 54 ]. Specifically, in one study, light physical activity could be performed, but for patients with an excessive urge to exercise, observation by a trained nurse was up to one-to-one supervision 24 hours a day [ 54 ]. In another study patients were first helped by physiotherapy, subsequently by physical education staff to engage at the advised activity level according to their physical health status (group sport/swimming to provide social activity and aerobic exercise in the maintenance phase) [ 33 ]. In another study, patients treated with treatment as usual (TAU) took part in graduated exercise therapy and were advised to elaborate an “exercise contract” with their therapist, while Healthy Exercise Behavior (HEB) Intervention patients engaged in a program aimed at reestablishing a “healthy” exercise behavior, reducing the compulsive quality of the exercise and re-experiencing social interaction and relaxation [ 43 ].

Psychopharmacological therapy

Among the analyzed inpatient treatments, only six addressed pharmacotherapy [ 39 , 44 , 50 , 53 , 54 , 56 ], indicating that patients could receive antipsychotics (three studies) [ 44 , 50 , 56 ], antidepressants (four studies) [ 44 , 50 , 53 , 56 ] and/or anxiolytics (three studies) [ 44 , 50 , 56 ]. Only one study mentioned the utilization of anticonvulsants as mood stabilizers [ 50 ]. One study cited the use of pharmacotherapy without providing specific details [ 54 ]. Another study simply stated that six out of 19 patients were taking antidepressants [ 53 ]. Notably, one study emphasized that pharmacotherapy was not considered a significant part of the therapeutic strategy, for its ineffectiveness in treating EDs symptoms; however, pharmacotherapy could be important for managing other comorbidities [ 39 ].

Admission and discharge criteria

Out of the 27 samples, 25 specified that the diagnosis of AN would be based on criteria from the ICD-10 (International Classification of Diseases 10th Revision), DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), or DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) [ 30 , 31 , 32 , 33 , 34 , 35 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 52 , 53 , 54 , 55 , 56 ]. However, only eight studies utilized BMI as a criterion for admission, with cut-off values specified in three studies as less than 17.5 [ 33 , 38 , 40 ], in two studies as less than 16 [ 35 , 50 ], and one each for less than 18.5 [ 47 ], less than 15 [ 43 ], and “low BMI at admission” [ 42 ]. Four studies mentioned additional general criteria, including increased/rapid/life-threatening weight loss, minimal food intake for several days, electrolyte imbalances, alcohol/drug abuse, life-threatening physical complications, suicide risk, chronic failure to benefit from outpatient treatment, family/social factors impeding recovery, pronounced purging or compulsive exercise, low insight, marked psychiatric comorbidity, and severity and chronicity of the illness [ 33 , 42 , 43 , 54 ].

Five studies employed BMI as a discharge criterion, three specifying a value equal to or greater than 20 [ 30 , 33 , 48 ], one equal to or greater than 19 [ 45 ], and another equal to or greater than 18 [ 38 ]. The mean delta BMI, from 13 studies that provided this information, is 2.32 [ 32 , 33 , 36 , 37 , 38 , 41 , 42 , 43 , 44 , 46 , 48 , 49 , 51 ]. The studies did not mention any other specific discharge criteria besides BMI.

Only two studies addressed mortality: one reported a mortality rate of 0% [ 37 ], while the other mentioned a rate of 1.47% [ 46 ].

Five studies specified the characteristics of the follow-up phase, with four outlining that patients could transition to ambulatorial outpatient care [ 33 , 42 , 43 , 54 ], two continuation to Day Hospital care [ 42 , 43 ], two mentioning residential treatment [ 37 , 43 ], and one indicating that patients might be transferred to a specialized psychiatric unit [ 54 ]. The remaining 22 studies did not provide details on the follow-up procedure.

Psychometric assessment

To assess ED psychopathology, 13 studies employed psychological scales. The majority (seven studies) used the Eating Disorder Examination (EDE, EDE-Q) [ 30 , 41 , 43 , 45 , 48 , 53 , 56 ], while five studies employed the Eating Disorder Inventory (EDI) [ 33 , 38 , 54 , 55 , 56 ]. Other scales included the Multiaxial Assessment of Eating Disorders Symptoms (MAEDS) [ 50 ], Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ) [ 41 ], Morgan–Russell Assessment Schedule (MRAS) [ 33 ], Body Shape Questionnaire (BSQ) [ 33 ], Body Checking Questionnaire (BCQ) [ 50 ], Overcoming Anorexia Nervosa Questionnaire (OANQ) [ 33 ], Anorectic Behaviour Observation Scale (ABOS) [ 33 ], Commitment to Exercise Scale (CES) [ 43 ], Compulsive Exercise Test (CET) [ 43 ], and the Structured Inventory for Anorexic and Bulimic Disorders for DSM-IV and ICD-10 (SIAB) [ 40 , 43 ].

Regarding general psychopathology, 12 studies utilized psychological scales [ 30 , 33 , 34 , 38 , 41 , 43 , 48 , 50 , 53 , 54 , 55 , 56 ]. Among these, five used the Beck Depression Inventory (BDI) [ 30 , 38 , 41 , 48 , 54 ], and four employed the Brief Symptom Inventory (BSI) [ 30 , 33 , 38 , 43 ]. Other scales included the State–Trait Anxiety Inventory (STAI) [ 41 ], EuroQoL EQ‐5D‐VAS [ 41 ], Working Alliance Inventory‐Short Revised (WAI-SR) [ 41 ], Culture-Free Self-Esteem Inventory (CFSEI) [ 33 ], Health & Daily Living Form (HDLF) [ 33 ], Symptom-Checklist-90-Revised (SCL-90-R) [ 34 ] and Hopkins Symptom Checklist (SCL-92) [ 56 ], the University of Rhode Island Change Assessment Scale-short version (URICA-S) [ 34 ], Multiperspective Assessment of General Change Mechanisms in Psychotherapy (SACIP) [ 34 ], Rosenberg Self-Esteem Scale (Rosenberg) [ 30 ], Generalized Anxiety Disorder 7 (GAD-7) [ 55 ], Patient Health Questionnaire (PHQ) [ 53 ], Perceived Stress Questionnaire (PSQ) [ 55 ], Gastrointestinal Symptom Rating Scale (GSRS) [ 55 ], Toronto Alexithymia Scale (TAS-20) [ 54 ], Hospital Anxiety and Depression Scale (HADS) [ 54 ], Perceived Stress Scale 10 (PSS-10) [ 54 ], Emotional Processing Scale (EPS) [ 53 ], Difficulties in Emotion Regulation Scale (DERS) [ 43 , 53 ], Clinical Impairment Assessment (CIA) [ 50 ], Brown Assessment of Beliefs Scale (BABS) [ 50 ], Padua Inventory (PI) [ 30 ] and Major Depression Inventory (MDI) [ 56 ].

The data of the present systematic review on a large sample confirm that adults affected by AN are usually young (mean 27.22 years) and with an average BMI of 14.20 that falls below the threshold for extreme severity as defined by DSM-5 [ 57 ]. The average length of stay in hospital is protracted but shorter than what was reported in literature from the 1990s onwards (59.35 days in the present review compared to 76.40 days in previous literature), confirming that, probably due to changes in the organization of health systems and/or the advancement of research, the length of stay is decreasing [ 58 ]. Furthermore, the average duration of the illness is 8.5 years, suggesting it is a long-lasting condition that often does not respond to initial treatments. This finding is consistent with the recent meta-analysis by Solmi and colleagues [ 4 ].

More in detail, this comprehensive analysis explores various facets of AN treatment, from refeeding practices and psychotherapeutic approaches to pharmacotherapy and diagnostic criteria. Despite advances in understanding AN, the varied descriptions and heterogeneous information in the studies seem to reflect the challenges in achieving consensus and uniformity within the field [ 59 , 60 ]. This challenge is also grounded in the complex task of translating guidelines into real-world practice. However, this heterogeneity not only underscores the complexity of AN, but also contributes to a lack of common information, compromising the ability to establish standardized protocols and reducing the generalizability of findings across different treatment settings.

In our review, approximately 81.48% of the studies provided insights into the clinical team, while 51.85% referenced using a psychotherapeutic model. Motivation was addressed in 25.93% of the studies, and all specified the treatment setting. Nutrition and refeeding protocols were detailed in 66.67% of the studies, while pharmacological therapy was mentioned in a small number of papers (22.22%). Admission or discharge criteria were described in 40.74% of the studies, and follow-up procedures were discussed in 14.81%. Additionally, 51.85% of the studies incorporated tests for assessment of the ED or general psychopathology. Approximately 50.62% of the studies, on average, presented information regarding key aspects of treatment, highlighting a lack of sufficient details about inpatient settings in ED treatments. This may hinder the possibility of a uniform description of interventions, pointing out a significant gap in the current research literature.

Treatment setting

The majority of guidelines, including the latest from the American Psychiatric Association [ 16 ], recommend the presence of a multidisciplinary team. However, less than half of the analyzed studies align with this indication and provide detailed information about the treatment team [ 33 , 37 , 39 , 41 , 42 , 43 , 46 , 48 , 49 , 54 , 55 , 56 ]. Typically, this team should include psychiatrists, dieticians, nurses, clinical psychologists, and internal medicine physicians, with regular team meetings and supervision emphasized [ 12 , 17 ]. However, the composition of these teams varied widely in the studies, and the presence of specific professionals was not consistently outlined. Since scientific articles also contribute to the establishment of new treatment centers, not specifying this data in detail is problematic. For example, the presence of a psychiatrist was explicitly mentioned in only 48.15% of the studies [ 33 , 36 , 37 , 39 , 41 , 43 , 46 , 48 , 49 , 50 , 52 , 54 , 56 ], possibly assumed to be implicit. The significance of nurses was highlighted in 37.04% of the studies [ 39 , 41 , 44 , 45 , 46 , 48 , 49 , 54 , 55 , 56 ], not recognizing enough the unique challenges they face in caring for hospitalized patients with EDs, including meal supervision, managing physical activity, and understanding psychopathological features [ 61 ]. Only 33.33% of the studies [ 37 , 39 , 41 , 42 , 44 , 46 , 48 , 49 , 56 ] acknowledged the role of dietitians, even though the American Dietetic Association itself emphasized the pivotal role of nutrition intervention as an integral component of team treatment for AN [ 62 ]. Finally, since medical stabilization and nutrition is a central element during hospitalization, the role of the doctor specialized in clinical nutrition is very little recognized and described, even though it is so essential. This flaw could arise from the fact that the majority of studies are carried out by mental health researchers. Adjunctive treatment recommendations were infrequently made, with only a few studies mentioning the presence of a physiotherapist (14.81%) [ 42 , 46 , 49 , 56 ], or an occupational therapist (7.41%) [ 33 , 48 ] among the total of studies. This limited acknowledgment of rehabilitation professionals overlooks the crucial role they play in addressing physical and functional aspects during inpatient treatment [ 63 , 64 ].

Psychotherapy

Although important for addressing psychological mechanisms, cognitive processes, behavioral patterns and providing emotional support, only some specific psychotherapies are recommended during hospitalization [ 1 ]. 51.85% of the studies referenced in the present review utilized some form of psychotherapy during inpatient treatment. Cognitive Behavioral Therapy [ 32 , 33 , 34 , 38 , 39 , 40 ] and Psychodynamic Therapy [ 33 , 41 ], employed by the majority of studies, are endorsed by several articles and reviews [ 65 , 66 , 67 , 68 ] and APA guidelines [ 16 ], which recommend ED–focused psychotherapy for adults with AN. Family Based Treatment, recommended for younger patients [ 69 ], was not prevalent, as our review excluded pediatric subjects. Individual psychotherapeutic management during acute renourishment can offer psychoeducation and support [ 70 ]; however, the initiation of psychotherapy in this acute phase should be tailored to the patient's medical stability and readiness, as recommended by the APA in 2023 [ 16 ]. Literature on psychotherapy during hospitalization is, in fact, ambivalent, with some studies considering it not effective in the acute phase, due to emaciation and negativism [ 71 ], and others evaluating it as promising and highlighting a better harmonization of treatments from inpatient to outpatient care [ 72 ]. This can partially explain in our sample the scarce number of studies specifying a psychotherapeutic approach. Two studies in our review also cited Cognitive Remediation and Emotion Skills Training (7.41%%) [ 31 , 32 ] as well as Cognitive Remediation Therapy (3.70%) [ 36 ], which are explored in novel research [ 73 , 74 , 75 ]. However, the studies that used a specific theoretical framework rarely detailed the weekly frequency of the sessions (18.52%) [ 34 , 38 , 40 , 41 , 43 ], and a few cited therapy groups (33.33%) [ 32 , 34 , 36 , 38 , 40 , 41 , 43 , 45 , 55 ] and parental counseling (18.52%) [ 32 , 33 , 39 , 41 , 45 ]. Furthermore, it is essential to consider that variations in adopting psychotherapeutic practices may stem from differences in the types of wards included in the studies. These practices are likely more prevalent in specialized units such as ED, general Psychiatry, or Psychosomatic units, as opposed to Internal Medicine or Physical Rehabilitation units. This datum seems to be confirmed by our review, in which 56.52% of the psychiatric units implement some form of psychotherapy, compared to 25% of the remaining settings. Again, future studies need to better define what clinical teams do and how they do it to psychologically support the patient. In fact, beyond formalized psychotherapies or more extensive psychological help in therapies-as-usual, defining how to support patients during hospitalization is mandatory.

Psychometric and motivation assessment

Although the use of an ED rating scale is not imperative to quantify eating and weight control behaviors, numerous patient and clinician-rated scales, along with screening tools for EDs, have been developed and validated [ 16 , 76 ]. Surprisingly in assessing ED psychopathology, only 13 studies (48.15%) [ 30 , 33 , 38 , 40 , 41 , 43 , 45 , 48 , 50 , 53 , 54 , 55 , 56 ] in our review employed psychological scales, with the most frequently used tests being the Eating Disorder Examination Questionnaire [ 77 , 78 ] (25.93%) [ 30 , 43 , 45 , 48 , 53 , 56 , 79 ] and the Eating Disorder Inventory [ 78 ] (18.52%) [ 33 , 38 , 54 , 55 , 56 ]. However, it is highlighted that in half of the studies there is no interest in evaluating through scores the improvement or the cognitive and behavioral aspects of the disease, which are maintenance factors and necessary to work on for recovery. It would be useful if a minimum set of psychometric scales were always included in studies on hospitalization. Even more so, there is a consensus in acknowledging EDE and EDI as the most reliable and broadly applicable ones for AN-specific symptomatology.

Conversely, the exploration of motivation in the context of AN was limited, with only seven studies addressing the topic (25.93%) [ 33 , 34 , 37 , 38 , 39 , 41 , 43 ]. Notably, only one study (3.70%) mentioned the implementation of a motivational interview before admission [ 38 ], despite the recognition that poor motivation is associated with treatment dropout and negative outcomes [ 80 , 81 ]. This points to a gap in the practice, given that motivation in AN is influenced by both psychological and biological factors inherent to the illness [ 82 , 83 ]. Also, motivation should be regarded as a pivotal factor, given its direct correlation with the severity of the condition. The greater the severity, the higher the likelihood of hospitalization, underscoring the imperative to address and enhance motivation in such cases.

Refeeding and nutrition

Nutritional treatment is the primary intervention in AN as well as in other EDs [ 4 ]. While oral nutrition is the preferred method in the studies analyzed for the review, being mentioned in the total of studies, there is no clear indication of the quantity, quality, and supervision of meals, resulting in some disparity between the various studies. This reflects a lack of standardized refeeding protocols regarding oral nutrition, contrary to the literature which suggests the implementation of specific supervised meal programs along with supervision training [ 18 ], and an insufficient definition of the importance of using liquid nutritional supplements [ 84 ]. Also, toilet-locking durations [ 33 , 40 , 44 ] or supervised rest after meals [ 54 ] are rarely mentioned (14.81%) and vary across studies.

In the treatment landscape of AN, refeeding for weight restoration is crucial, but practices lack standardization, relying on clinical expertise [ 70 ]. Oral nutrition is recommended as the primary treatment, while NGT feeding has limited impact on normalizing food intake or diversifying the diet [ 18 ] and should be considered a short-term intervention before transitioning to oral intake [ 16 ] in severely malnourished patients [ 18 ] or when fear of weight gain poses challenges to oral nutrition [ 85 ]. However, only ten studies (37.04%) in our review discussed NGT as a choice of treatment [ 33 , 37 , 38 , 41 , 42 , 44 , 46 , 47 , 49 , 52 ], usually as a secondary strategy after an initial attempt with entirely oral nutrition (29.63%) [ 33 , 37 , 38 , 41 , 42 , 44 , 47 , 52 ]. Thus, the criteria for its implementation and the categorization of NGT as a primary or secondary treatment are infrequently specified in our sample and exhibit variation across studies. Also, aspects of tolerance, acceptability, and psychological education of the patient are not cited, although they should be integral components of the programs [ 86 ].

According to the consensus on weight gain for patients with AN [ 16 ], only 25.93% of the studies in our review indicate a weekly weight gain target within the range of 0.5–1.5 kg [ 38 , 43 , 44 , 45 , 47 , 49 , 56 ]. This aligns with the established recommendation to balance concerns about refeeding syndrome [ 87 ] and patient tolerance [ 88 ], even though some researchers suggest further research on faster weight restoration [ 45 ]. Overall, it is important to emphasize that not only the target weight, but also the pattern of weight gain (trajectory), which considers fluctuations and is highly personalized, is a crucial aspect [ 89 , 90 ]. Unfortunately, our sample of studies did not explore this aspect so crucial for patients and clinicians.

Regarding caloric intake, diverse studies proposed different approaches, with two recommending a gradual increase starting from 50% of individual basic energy needs [ 42 , 44 ] and another suggesting an initial intake of 1500 kcal/day [ 33 ]. These findings (11.11%) align with the current trend of using higher initial caloric prescriptions and faster rates of renourishment under close medical monitoring, with electrolyte correction as needed [ 18 , 91 , 92 ]. In contrast, one study (3.70%) mentioned an initial prescription of 600–1400 kcal/day [ 52 ], reflecting historical concerns about refeeding syndrome [ 16 ]. Final caloric intakes are specified to be between 3000–4000 kcal/day in 11.11% of the studies [ 45 , 51 , 52 ], in line with literature recommending higher energy intake in individuals with a high rise in energy expenditure [ 93 , 94 ]. Conversely, another study (3.70%) opted for a non-hypercaloric diet (1700 kcal/day) to achieve a minimum weight compatible with health [ 39 ]. These data highlight a persistent variance in clinical practice regarding caloric prescription, likely influenced by clinical judgment and personal preference. Unfortunately, none of the studies mention the importance of discussing this crucial aspect [ 95 ] with the patient.

Interestingly, while there is limited literature on physical therapy in AN suggesting the potential benefits of aerobic exercise and yoga [ 96 ], four studies (14.81%) in our research delved into this aspect [ 33 , 43 , 49 , 54 ], with one implementing a Healthy Exercise Behavior intervention [ 43 ]. Current knowledge suggests that incorporating physical activity during the refeeding of patients with AN is safe and beneficial for restoring body composition and bone mineral density, as well as improving mood and anxiety [ 64 ].

Admission, discharge, and follow-up

The admission and discharge criteria for AN lack a strict definition in the studies under review. Criteria for admission are described only in 33.33% of the studies and include low BMI, rapid or life-threatening weight loss, minimal food intake, electrolyte imbalances, alcohol/drug abuse, physical complications, suicide risk, chronic failure to benefit from outpatient treatment, family/social factors, pronounced purging or compulsive exercise, and marked psychiatric comorbidity [ 33 , 35 , 38 , 40 , 42 , 43 , 47 , 50 , 54 ]. However, these norms only partially correspond to the more defined criteria outlined in the most recent APA guidelines, as the latter include specific levels of heart rate (< 50 bpm), blood pressure (< 90/60 mmHg), glucose (< 60 mg/dL), electrolytes, temperature (< 36 °C), rapidity of weight change (> 10% in 6 months), and ECG abnormalities (QTc > 450 ms) [ 16 ]. This suggests that in clinical practice, hospitalization is often influenced not only by standard guidelines criteria, but also by environmental factors, concurrent psychiatric symptoms, and “clinical wise”. While this individualized approach may be relevant for each patient, the lack of consistency could lead to a situation where treatment varies significantly between centers. Moreover, the APA defines BMI < 15 as a possible criterion for hospitalization but cautions against relying solely on this parameter for severity assessment and admission decisions, considering factors such as the rate of weight loss, even at non-extreme BMI.

Additionally, only five studies (18.52%) in our review employed BMI as a discharge criterion [ 30 , 33 , 38 , 45 , 48 ], and the mean delta BMI from the 13 studies that reported it is 2.32 [ 32 , 33 , 36 , 37 , 38 , 41 , 42 , 43 , 44 , 46 , 48 , 49 , 51 ]. The latter represents a significant outcome and seems to reflect the effectiveness of hospitalization, despite variations in practices. However, it is important to note the difference in the length of stay of the studies included (see Table  1 ) and recognize that BMI alone does not provide a comprehensive assessment of treatment efficacy and effectiveness. For example, weight gain trajectory was proposed as a relevant outcome [ 97 ]. Also, apart from BMI, the studies did not mention any other specific discharge criteria. This indicates a lack of information about other parameters, which are probably considered outcome criteria, such as the stabilization of medical conditions, compliance with the dietary plan, familial and social factors, and the treatment of comorbidities [ 79 , 98 ]. We also have to consider that in treating AN, reliance on DSM criteria alone for discharge decisions poses significant challenges: many patients discharged based on these criteria (i.e., weight for partial remission) remain at high risk for relapse due to unresolved psychological or behavioral issues. This situation often results in a 'revolving door' phenomenon, where patients repeatedly enter and exit treatment [ 79 ].

Addressing the importance of a well-defined care plan, the NICE guidelines stress the significance of articulating how patients will be discharged and reintegrated into community-based care [ 10 ]. However, our sample revealed that the transition of AN patients to various care settings (e.g., Day Hospital, outpatient treatment, residential center) was explored in only five studies (18.52%) [ 33 , 37 , 42 , 43 , 54 ]. The challenges associated with the termination of inpatient treatment like discontinuity of care [ 20 ] and the high post-discharge relapse rates [ 99 ] underscore the need for a clearer definition of interventions following hospitalization.

As echoed in both guidelines and clinical practice, pharmacotherapy is not the primary treatment for AN, and, although frequently used, is associated with low recovery rates [ 4 ]. In particular, limited evidence supports the use of antidepressants for weight gain during nutritional rehabilitation; however, the established practice involves an integrated approach to medications for managing specific symptoms and comorbidities [ 9 ]. These compounds, especially selective serotonin reuptake inhibitors or SSRIs, are therefore commonly prescribed [ 100 , 101 , 102 ], accounting for more than 35% of the patients in our review [ 44 , 50 , 53 , 56 ] and reflecting the relevance of depressive comorbidity in AN [ 103 ]. Also, the off-label use of antipsychotics, notably olanzapine and aripiprazole, is frequent in AN treatment [ 104 , 105 , 106 , 107 ], reflected in about 20% of the patients in this review [ 44 , 50 , 53 , 56 ]. In some cases of AN, mood stabilizers may be prescribed, typically in the presence of mood or personality disorders in comorbidity [ 108 ], although they are not considered a first-line treatment for AN, constituting only 3% of patients in our review [ 50 ]. Benzodiazepines and anxiolytics are frequently used for the temporary treatment of anxious symptoms and sleep–wake cycle disturbances [ 109 ], accounting for more than 25% of patients in the present study [ 44 , 50 , 56 ]. While pharmacotherapy is commonly used in real-world practice, it is then important to note that the majority of the included studies (77.78%) omitted important data about the presence of pharmacologic treatment, and the six that reported lacked relevant information about the specific compounds used, the rationale for the treatment, and data about treating comorbid conditions.

Hospitalization is a crucial phase in the treatment pathways for individuals with AN. In this setting they are encountered during the most acute, severe, and thus challenging conditions, making it essential to propose consistent and appropriate treatments in line with established guidelines. However, our review outlines the presence, in clinical practice, of a wide range of criteria, objectives, and treatment forms, posing a risk of inconsistency and deviation from evidence-based medicine.

Although the majority of studies cited some members of the clinical team, only less than half provided detailed information on a multidisciplinary team. The studies also showed significant variation in composition: specific professionals, such as psychiatrists and nurses, were inconsistently outlined. This contrasts with the knowledge that EDs are complex diseases that need treatment by a wide range of healthcare figures [ 110 ].

The therapeutic field also lacks uniformity, particularly in the implementation of psychotherapy, with no consensus on its necessity in the acute phase, a fragmentation of the data about the type of psychotherapeutic approach, and a notable deficiency in the focus on motivation within treatment. Few studies addressed pharmacotherapy, contrasting with its widespread use in clinical reality to treat comorbid symptoms. Moreover, the reports not only lack details on the medications used, but also on the treatment rationale, interactions with other proposed treatments, side effects, and patient adherence. It is also worth noting that the previous review from Suárez and colleagues [ 21 ] included greater detail regarding pharmacological treatments, while our work evidenced a lack of reporting on the same theme: this may potentially shed light on a sort of slowdown in advancements in this field during the last decade [ 111 ].

Furthermore, our review also highlights a lack of strict definitions for admission and discharge criteria, influenced by environmental factors and psychiatric symptoms. It is noteworthy to consider that while there may be criteria in practice, their absence in the studies suggests an underreporting or lack of clear treatment goals. Discharge parameters beyond BMI are rarely mentioned, indicating a potential gap in the identification of outcome criteria. Transition to various care settings post-hospitalization, crucial for patient care and relapse prevention, was explored in only five studies.

In terms of nutrition, oral rehabilitation is preferred, consistent with clinical guidelines. However, there is a disparity in the quantity, quality, and supervision of meals across studies. Also, although guidelines specify certain criteria for the introduction of nasogastric tubes and the target weight gain, there is a lack of standardized refeeding protocols and inconsistent mention of measures of behavioral control (e.g., toilet-locking duration, supervised rest).

In conclusion, our review exposes the incomplete and heterogeneous nature of descriptions surrounding AN inpatient treatments, from refeeding protocols to psychotherapeutic and pharmacotherapeutic approaches, outlining inconsistent reporting practices. While it is well established that in the real-world treatments may be different from the gold standards of international guidelines [ 112 ], it could be helpful, when presenting results for a scientific paper to offer a complete description of treatment settings, especially regarding inpatients units, and to implement the use of uniform reporting of the practices.

Future studies should comprehensively detail team composition, clinical orientation, pharmacological and nutritional treatments, admission criteria, discharge goals, and psychotherapy or rehabilitative interventions. A further effort in describing treatments in this complex field is commendable, also given the fact that EDs risk being considered a niche in actual research [ 113 ], and thus, individuals with ED risk receiving inconsistent and non-gold standard treatments.

Further studies should delve deeper into inpatient treatment approaches, elucidating the reasons for implementation and their advantages/disadvantages: this would enhance the medical community's understanding of alternative treatments, their benefits, and impacts, contributing to the development of universal guidelines for a more cohesive and scientifically supported treatment reality.

Strengths and limits

The strengths of this review lie in its comprehensive examination of various aspects of AN inpatient treatments, providing insights into the diverse criteria, objectives, and treatment forms present in clinical practice. A potential limitation could be the heterogeneity among the included studies, which may impact the generalizability of findings. The variation in study designs, populations, clinical settings, and methodologies may limit the ability to draw uniform conclusions applicable across diverse settings and patient groups. Additionally, an inherent challenge lies in the ambiguity of whether the lack of certain data stems from them just not being described in papers, indicating potential hidden criteria that may align with established guidelines, or from the absence of use of criteria, resulting in patients receiving heterogeneous treatments among different centers.

Data availability

Datasets are available on request through contact with the corresponding author.

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Acknowledgements

We express our gratitude to the late Enrica Marzola, whose insightful expertise and guidance were invaluable during the preparation of the initial draft of this manuscript.

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Toppino, F., Martini, M., Longo, P. et al. Inpatient treatments for adults with anorexia nervosa: a systematic review of literature. Eat Weight Disord 29 , 38 (2024). https://doi.org/10.1007/s40519-024-01665-5

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Research offers hope and reassurance for adults with eating disorders

by Curtin University

New Curtin University research has found an inpatient treatment approach can help adults with eating disorders improve not only their physical health, but also their psychological health. The research is published in the Journal of Eating Disorders .

"High-energy refeeding" is frequently used to treat malnourished adolescents with anorexia nervosa and involves patients consuming a progressively higher energy intake over a short period of time, to quickly restore their nutritional health.

It's been thought this approach could prove problematic when treating adults with the same condition. However, this may not be the case.

Researchers from Curtin's School of Population Health investigated 97 voluntary hospital inpatients (55 adults and 42 adolescents) with eating disorders, the majority anorexia nervosa, who were treated using a high-energy refeeding protocol.

The team found both age groups responded well to high-energy refeeding, reporting very similar positive weight change and improvements in measurements of their psychological health .

Masters student and study lead Fiona Salter said there had been previous concerns that adult patients undergoing high-energy refeeding could be at increased risk of developing refeeding syndrome, a potentially fatal condition which can occur when a severely malnourished person starts eating again and causes a sudden shift in fluid and electrolytes.

"In addition, more frequent mental health issues in adult patients could complicate their medical care ," Ms. Salter said. "However, only one adult participant in our study did not tolerate the high-energy protocol due to oedema, which is an excess of fluid accumulating in body tissues."

Study co-author Dr. Emily Jeffery said the findings indicate high-energy refeeding in adults who are mildly and moderately malnourished can be administered safely and has both nutritional and psychological benefits.

"However, clinicians need to be aware [that] severely malnourished adults may require adjustments to prevent complications," Dr. Jeffery said.

Ms. Salter said the improvements in adult patients ' psychological well-being were critically important in using high-energy refeeding in the future.

"There was some concern feeding too quickly could put them under too much distress, which is why we wanted to measure these psychological scores," Ms. Salter said.

"We found psychosocial questionnaire scores improved significantly over the hospital admission, but psychological recovery from an eating disorder takes months and years, so while it's great we can physically restore someone's nutritional health quite quickly, the important thing is to keep that going. It needs to be maintained after they leave hospital for their longer-term psychological recovery."

With this in mind, Ms. Salter said the next step was to see how patients with a similar severity of illness respond to high-energy refeeding in a less structured environment, such as an intensive treatment day program.

"We'll be investigating whether a similar high energy refeeding protocol to that used in the hospital study has the same outcomes when patient meals are only partially supervised," she said.

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• Introduction
• Conclusions
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In Canada, the COVID-19 pandemic started in month 63 (March 1, 2020). The shading indicates the 95% CIs, blue circles, cases (A) and hospitalizations (B) per month before the first wave of the pandemic; blue line, prepandemic trend line of cases (A) and hospitalizations (B); orange diamonds, cases (A) and hospitalizations (B) per month during the first wave of the pandemic; orange line, trend line of cases (A) and hospitalizations (B) during the first wave of the pandemic.

eFigure 1. Interrupted Time Series of New Anorexia Nervosa/Atypical Anorexia Nervosa Cases per Month (With 95% Confidence Interval) by Study Site, January 2015 to November 2020

eFigure 2. Interrupted Time Series of Hospitalizations for New Anorexia Nervosa/Atypical Anorexia Nervosa per Month (With 95% Confidence Interval) by Study Site, January 2015 to November 2020

• Critical Escalation of de Novo Pediatric Anorexia Nervosa JAMA Network Open Invited Commentary December 7, 2021 Youngjung Kim, MD, PhD

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Agostino H , Burstein B , Moubayed D, et al. Trends in the Incidence of New-Onset Anorexia Nervosa and Atypical Anorexia Nervosa Among Youth During the COVID-19 Pandemic in Canada. JAMA Netw Open. 2021;4(12):e2137395. doi:10.1001/jamanetworkopen.2021.37395

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Trends in the Incidence of New-Onset Anorexia Nervosa and Atypical Anorexia Nervosa Among Youth During the COVID-19 Pandemic in Canada

• 1 Division of Adolescent Medicine, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Quebec, Canada
• 2 Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Quebec, Canada
• 3 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
• 4 Section of Adolescent Medicine, Department of Pediatrics, Sainte Justine Hospital, Université de Montréal, Montreal, Quebec, Canada
• 5 Division of Adolescent Medicine, Department of Pediatrics, McMaster’s Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
• 6 Section of Adolescent Medicine, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
• 7 Faculty of Social Work, Departments of Pediatrics and Psychiatry, University of Calgary, Calgary, Alberta, Canada
• 8 Division of Adolescent Medicine, Department of Pediatrics, Janeway Children’s Hospital, Memorial University, St John’s, Newfoundland, Canada
• 9 Department of Psychiatry, University of British Columbia, and Provincial Specialized Eating Disorders Program for Children and Adolescents, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
• Invited Commentary Critical Escalation of de Novo Pediatric Anorexia Nervosa Youngjung Kim, MD, PhD JAMA Network Open

Question   Is the COVID-19 pandemic associated with a change in the incidence and hospitalization rates for new-onset anorexia nervosa or atypical anorexia nervosa among youth?

Findings   In this cross-sectional study of 1883 children and adolescents with newly diagnosed anorexia nervosa or atypical anorexia nervosa, the incidence of the disease increased from 24.5 to 40.6 cases per month and hospitalizations among these patients increased from 7.5 to 20.0 per month. During the first wave of the pandemic, the onset of illness was more rapid and disease severity was greater at presentation than before the pandemic.

Meaning   Findings of this study suggest a need for expansion of eating disorder services as well as research to better understand the drivers and prognosis for this pediatric population.

Importance   The COVID-19 pandemic has had considerable mental health consequences for children and adolescents, including the exacerbation of previously diagnosed eating disorders. Whether the pandemic is a factor associated with the concomitant increase in new-onset anorexia nervosa or atypical anorexia nervosa remains unknown.

Objective   To assess the incidence and severity of newly diagnosed anorexia nervosa or atypical anorexia nervosa in a national sample of youth before and during the first wave of the COVID-19 pandemic.

Design, Setting, and Participants   This repeated cross-sectional study analyzed new eating disorder assessments that were conducted at 6 pediatric tertiary-care hospitals in Canada between January 1, 2015, and November 30, 2020. Patients aged 9 to 18 years with a new anorexia nervosa or atypical anorexia nervosa diagnosis at the index assessment were included.

Exposures   COVID-19–associated public health confinement measures during the first wave of the pandemic (March 1 to November 30, 2020).

Main Outcomes and Measures   Primary outcomes were the incidence and hospitalization rates within 7 days of de novo anorexia nervosa or atypical anorexia nervosa diagnosis. Event rate trends during the first wave were compared with trends in the 5-year prepandemic period (January 1, 2015, to February 28, 2020) using an interrupted time series with linear regression models. Demographic and clinical variables were compared using a χ 2 test for categorical data and t tests for continuous data.

Results   Overall, 1883 children and adolescents with newly diagnosed anorexia nervosa or atypical anorexia nervosa (median [IQR] age, 15.9 [13.8-16.9] years; 1713 female patients [91.0%]) were included. Prepandemic anorexia nervosa or atypical anorexia nervosa diagnoses were stable over time (mean [SD], 24.5 [1.6] cases per month; β coefficient, 0.043; P  = .33). New diagnoses increased during the first wave of the pandemic to a mean (SD) of 40.6 (20.1) cases per month with a steep upward trend (β coefficient, 5.97; P  < .001). Similarly, hospitalizations for newly diagnosed patients increased from a mean (SD) of 7.5 (2.8) to 20.0 (9.8) cases per month, with a significant increase in linear trend (β coefficient, −0.008 vs 3.23; P  < .001). These trends were more pronounced in Canadian provinces with higher rates of COVID-19 infections. Markers of disease severity were worse among patients who were diagnosed during the first wave rather than before the pandemic, including more rapid progression (mean [SD], 7.0 [4.2] months vs 9.8 [7.4] months; P  < .001), greater mean (SD) weight loss (19.2% [9.4%] vs 17.5% [9.6%]; P  = .01), and more profound bradycardia (mean [SD] heart rate, 57 [15.8] beats per minute vs 63 [15.9] beats per minute; P  < .001).

Conclusions and Relevance   This cross-sectional study found a higher number of new diagnoses of and hospitalizations for anorexia nervosa or atypical anorexia nervosa in children and adolescents during the first wave of the COVID-19 pandemic in Canada. Research is needed to better understand the drivers and prognosis for these patients and to prepare for their mental health needs in the event of future pandemics or prolonged social isolation.

The COVID-19 pandemic has had adverse implications for both the physical and mental health of children and adolescents worldwide. 1 - 7 The World Health Organization declared COVID-19 a pandemic on March 11, 2020. Shortly after this declaration, public health mitigation strategies were mandated throughout Canada. By mid-March, Canadian provinces and territories had abruptly implemented, to varying degrees, school closures, prohibitions on gatherings, closures of nonessential businesses, and cancellation of sports and extracurricular activities. Public health authorities also cautioned against unnecessary visits to health care facilities to reduce viral transmission and to maintain capacity to accommodate surges in COVID-19 cases. 1 Pediatric hospitals worldwide experienced decreased emergency department (ED) visits and hospital admissions throughout 2020. 2 - 4 Despite the substantial reduction in the number of children and adolescents brought into hospitals for medical attention during the pandemic, numerous studies have reported increased pediatric mental health visits. 5 - 7

The association between stressful events and exacerbations in eating disorder symptoms has been documented. 8 Studies of adult patients with preexisting eating disorders reported worsening symptoms during the first wave of the COVID-19–associated confinement, including greater caloric restriction, increased self-induced vomiting, worsening body dysmorphia, and heightened exercise drive. 9 - 11 Two single-center studies from Australia also found an increase in hospitalizations during the first wave of the pandemic among adolescents with previously diagnosed anorexia nervosa. 12 , 13 Similarly, a recent single-center study in the US reported a doubling of hospitalizations for restrictive eating disorders during the COVID-19 pandemic. 14 To date, the association between the pandemic and its confinement measures and the genesis of new-onset anorexia nervosa or atypical anorexia nervosa has not been studied. In this study, we sought to assess the incidence and severity of newly diagnosed anorexia nervosa or atypical anorexia nervosa in a national sample of children and adolescents before and during the first wave of the COVID-19 pandemic.

This cross-sectional study was approved by the Research Ethics Board at each of the 6 participating institutions in Canada (Alberta Children’s Hospital, Calgary, Alberta; British Columbia Children’s Hospital, Vancouver, British Columbia; Janeway Children’s Hospital, St John’s, Newfoundland; McMaster Children’s Hospital, Hamilton, Ontario; Montreal Children’s Hospital, Montreal, Quebec; and Sainte Justine Hospital, Montreal, Quebec). Approval to waive direct patient consent was obtained from the Research Ethics Board at these sites for reasons of feasibility. We followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline. 15

We conducted a repeated cross-sectional analysis of all new eating disorder assessments between January 1, 2015, and November 30, 2020, at 6 of the 10 Canadian pediatric hospitals with tertiary-level eating disorder programs, which span 5 Canadian provinces from the western to the eastern coasts. Each of these 10 eating disorder programs were invited to participate in the study. At all of the participating study sites, the adolescent medicine service is involved with the assessment of consultations for youth younger than 18 years with symptoms that are suggestive of eating disorders. The referral sources for each program include community physicians, hospital subspecialists, and EDs that assess patients with acute presentations. Those who are diagnosed with an eating disorder and severely malnourished at the time of presentation are hospitalized for medical stabilization and nutritional rehabilitation. Admission criteria for patients with an eating disorder that are common to all study sites include full food refusal and/or evidence of substantial cardiovascular compromise (resting heart rate <50 beats per minute [bpm] and/or systolic blood pressure <90 mm Hg), as outlined by guidelines from the Society for Adolescent Health and Medicine. 16 All 6 sites continued to conduct new eating disorder assessments throughout the study period (March 1 to November 30, 2020).

Patients were included in this study if they were aged 9 to 18 years and received a new diagnosis of anorexia nervosa or atypical anorexia nervosa, according to recognized definitions of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) ( DSM-5 ). Because the DSM-5 does not identify a specific weight threshold for atypical anorexia nervosa, patients with a percentage of median body mass index (BMI) that was greater than 85% at the time of assessment were classified as having atypical anorexia nervosa, as described elsewhere. 17 Patients were excluded if they met the criteria for a DSM-5 eating disorder other than anorexia nervosa or atypical anorexia nervosa (eg, avoidant restrictive food intake disorder, bulimia nervosa, and binge eating disorder) or if their diagnosis remained unclear after the initial assessment. Patients who were diagnosed with an eating disorder before the index assessment were also excluded from analysis. Metrics on race and ethnicity were not collected because these are not routinely included at Canadian databanks or medical records.

The primary outcome measures were the incidence and hospitalization rates within 7 days of de novo anorexia nervosa or atypical anorexia nervosa diagnosis. Secondary outcomes included eating disorder–specific variables of interest that were obtained from patient medical records: self-reported duration of restrictive behaviors before assessment, vital signs at time of assessment, percentage of median BMI, percentage of body weight loss, and amount and rate of weight loss. Baseline demographic data were also collected, including age, sex assigned at birth, BMI at assessment, and index visit diagnosis. The World Health Organization growth curves for age and sex were used to calculate median BMI. Premorbid weight and amount and rate of weight loss were calculated according to the growth records at the time of the assessment. When not available, premorbid weight was based on self-reported information.

The main exposure was COVID-19–associated public health confinement measures. For the purpose of this analysis, the beginning of the pandemic period was defined as March 1, 2020, which corresponded with the earliest public health recommendations that slightly preceded the official provincial state-of-emergency declarations and lockdown measures across Canada (from March 13 to 27, 2020). 18 The prepandemic period was defined as January 1, 2015, to February 28, 2020.

Incidence and hospitalization rates for all de novo anorexia nervosa or atypical anorexia nervosa diagnoses during the first wave of the pandemic were compared with rates in the 5-year prepandemic period. Monthly counts were plotted for the number of new cases and for the number of patients requiring medical hospitalization within 7 days of their index presentation or diagnosis.

We performed an interrupted time series analysis with linear regression modeling to estimate time trends (and 95% CIs) in national monthly event rates before and during the first wave of the pandemic as well as to identify the change in time trends associated with COVID-19 (March 2020) and the immediate implication of COVID-19 for the event rate (equivalent to the mean difference between pre- and post-COVID-19 event rates, controlling for time trends). In addition to pooled national-level analyses, site-specific charts were plotted and analyzed for each of the 6 study sites. Autocorrelation was assessed between months using Durbin-Watson tests and was further validated for the interrupted time series with the Newey-West adjustment for SE, which also demonstrated no correlation.

No data were missing for the primary or secondary analyses. Baseline demographic and clinical data for eating disorder–specific variables were presented in descriptive tables and were compared before and during the first wave of the pandemic using either a χ 2 test for categorical data or an unpaired t test for continuous data. A 2-tailed P  < .05 was considered statistically significant. All analyses were performed using SAS, version 9.4 (SAS Institute).

A total of 1883 children and adolescents (median [IQR] age, 15.9 [13.8-16.9] years; 1713 female [91.0%] and 170 male [9.0%] youth) who were newly diagnosed with anorexia nervosa or atypical anorexia nervosa across the 6 study sites were included in the analysis. The number of patients included from each site and their baseline characteristics before and during the first wave of the COVID-19 pandemic are shown in Table 1 . Most patients were diagnosed with atypical anorexia nervosa both before (783 of 1538 [50.8%]) and during (175 of 345 [50.7%]) the first wave.

The time trends of total newly diagnosed cases and hospitalizations per month in the pooled national sample are shown in the Figure . For the 5-year period preceding the pandemic, the time trend was stable over time (β coefficient, 0.043; P  = .33), and the mean (SD) number of newly diagnosed cases during this period was 24.5 (1.6) cases per month ( Table 2 ). During the first wave, newly diagnosed cases demonstrated a steep upward trend (β coefficient, 5.97; P  < .001), and the mean (SD) cases during this period increased to 40.6 (20.1) cases per month ( P  < .001). Hospitalizations for new patients similarly increased sharply along with the pandemic (β coefficient, −0.008 vs 3.23; P  < .001), with the mean (SD) cases increasing from 7.5 (2.8) cases per month to 20.0 (9.8) cases per month ( P  < .001).

To assess for site-specific trends, new anorexia nervosa or atypical anorexia nervosa cases (eFigure 1 in the Supplement ) and hospitalizations (eFigure 2 in the Supplement ) were also analyzed by study site. Hospitals located in the Central Canadian provinces of Ontario and Quebec demonstrated the greatest increases in mean (SD) number of monthly cases (5.1 [2.3] to 10.4 [5.7] for McMaster Children’s Hospital; 4.5 [2.3] to 8.7 [5.9] for Montreal Children’s Hospital; and 5.8 [2.2] to 11.7 [6.7] for Sainte Justine Hospital) and monthly hospitalizations (2.2 [1.5] to 6.6 [4.1] for McMaster Children’s Hospital; 0.8 [1.0] to 3.6 [2.6] for Montreal Children’s Hospital; and 1.6 [1.3] to 5.0 [3.6] for Sainte Justine Hospital) during the first wave of the pandemic ( Table 2 ). Upward linear trends at these sites most resembled the pooled national sample. Linear trends in hospitalizations at 2 additional sites (Alberta Children’s Hospital and Janeway Children’s Hospital) approached significance compared with prepandemic trends. Only 1 study site experienced no change in linear trend for new cases or hospitalizations compared with the prepandemic period (British Columbia Children’s Hospital).

To better understand the concomitant increase in hospitalizations, markers of anorexia nervosa severity were compared before and during the first wave of the pandemic for patients with newly diagnosed anorexia nervosa or atypical anorexia nervosa at all sites that reported an increase in newly diagnosed cases ( Table 3 ). At these sites, all in Central Canada, patients with a new diagnosis during the pandemic had a shorter mean (SD) duration of restrictive symptoms (7.0 [4.2] months vs 9.8 [7.4] months; P  < .001), with a higher mean (SD) percentage of body weight lost (19.2% [9.4%] vs 17.5% [9.6%]; P  = .01) at a faster mean (SD) rate (2.1 [2.0] kg/mo vs 1.6 [1.7] kg/mo; P  < .001). Moreover, these patients presented with more profound bradycardia at diagnosis (mean [SD] heart rate, 57 [15.8] bpm vs 63 [15.9] bpm; P  < .001), with a greater proportion of patients meeting clinical criteria for admission compared with patients who were diagnosed before the pandemic (45.8% [121 of 264] vs 32.6% [317 of 972]; P  < .001).

To our knowledge, this study was the first to evaluate the association between the COVID-19 pandemic and new-onset anorexia nervosa or atypical anorexia nervosa in any patient population. In a broad national sample of youth who underwent an assessment in a tertiary care setting during the first wave of the pandemic, monthly cases of new-onset anorexia nervosa or atypical anorexia nervosa increased by more than 60% (24.5 to 40.6), and monthly hospitalizations nearly tripled (7.5 to 20.0) compared with prepandemic rates. Linear trends for both new cases and hospitalizations increased sharply, concomitant with pandemic confinement measures that began in March 2020. At sites with the greatest number of new cases, patients who received a diagnosis during the pandemic presented with more rapidly evolving and more severe markers of disease, which likely explains the observed increase in hospitalizations.

The largest increase in both new diagnoses and hospitalizations of anorexia nervosa or atypical anorexia nervosa was reported in Central Canada provinces (Quebec and Ontario). In these provinces, cases of COVID-19 and related mortality per capita were the highest during the first wave of the pandemic, 18 and therefore the most restrictive confinement measures were adopted. 19 In contrast, Western Canada reported relatively small growth in COVID-19 cases, and few cases were reported in Atlantic Canada. 19 These findings suggested that provinces with high cases of COVID-19 infections and stricter confinement measures experienced a higher burden of newly diagnosed anorexia nervosa and atypical anorexia nervosa.

Provincial variations in the management of health services (eg, closures of primary care practices) may also be a factor in the differences between sites in the number of eating disorder assessments that were performed during the first wave of the pandemic. Some studies reported increases in acute mental health presentations at the ED 6 , 7 ; however, it is unclear how these observations can be interpreted in the context of the pandemic. During the first wave, pediatric hospitals experienced dramatic decreases in ED visits and hospitalizations. 3 , 4 Mental health presentations increased as a proportion of these visits, 20 but not necessarily in absolute number. Moreover, in many provinces in Canada, public health authorities also mandated the closure of primary care clinics, limiting access to other mental health community resources. Therefore, analyses of ED visits and hospitalizations from the ED for anorexia nervosa or atypical anorexia nervosa may overestimate the true incidence. A strength of the present study was the inclusion of eating disorder assessments from a broad catchment of referral sources (outpatient clinics, inpatient wards, and EDs) at all study sites. As such, this study likely more accurately estimated the true burden of new-onset anorexia nervosa or atypical anorexia nervosa during the first wave than analyses of ED visits and hospitalizations alone.

The increase in new anorexia nervosa or atypical anorexia nervosa diagnoses during the first wave of the COVID-19 pandemic is likely multifactorial. Patients who were previously diagnosed reported experiencing worsening symptoms because of the pandemic. 9 - 11 A recent single-center study at an adolescent eating disorder program found that, across all eating disorders, 40% of newly diagnosed patients cited the pandemic as a trigger for their eating disorder. 21 Interviews conducted with adults with an eating disorder revealed an exacerbation of symptoms that was associated with increased anxiety, social isolation, and reduced contact with their treatment teams. 9 , 22 Moreover, adults also reported worsening eating disorder symptoms in conjunction with a lack of distractions and constant exposure to stressful messages on social media. 23 It is possible that these same stressors play a role in new-onset anorexia nervosa or atypical anorexia nervosa among children and adolescents.

COVID-19–associated restrictions varied in intensity and duration across Canada, but all provinces initially closed schools and nonessential businesses and canceled extracurricular activities. These changes had substantial consequences for eating, physical activity, and social patterns of adolescents, each of which may be a risk factor for developing anorexia nervosa cognitions. 23 Lack of a clear routine may be associated with a higher risk for eating disorder–related behaviors because it removes structures that normalize eating. Confinement orders limit access to regular physical activity, which, in combination with disrupted eating patterns, may have a role in the heightened concern about body shape and weight. 24 In addition, school closures likely expand social media use as a means of communication with peers. Media use has been associated with an increased risk for disordered eating, in particular through exposure to thin ideals and diet-related content. 25 Furthermore, social media trends referring to weight gain during confinement and a focus on home cooking and exercise routines may have further elevated the eating disorder risk among youth.

Many adolescents with an eating disorder also have comorbid psychopathology, including depression, anxiety, and obsessive-compulsive disorder. 26 Evidence suggests that the COVID-19 pandemic has had detrimental consequences for the mental health of both youths and their parents. 5 - 7 , 27 Rates of depression and suicidal ideation were higher in adults in COVID-19–associated lockdowns compared with those who were not under these restrictions. 28 In children and adolescents, the disruption of routines and disconnection from peers were associated with the increase in mental health burden and emergence of depression and anxiety. 20 , 29 A worsening of overall mental health status may explain the increased rate of newly diagnosed anorexia nervosa or atypical anorexia nervosa found in the present study.

Protective factors against eating disorders in youth were also disrupted by the COVID-19 pandemic. Social support has been identified as a protective factor during stressful periods and as key to managing and reducing disordered eating. 30 During the first wave of the pandemic, most countries used social distancing measures as a primary public health mitigation strategy. Many children and adolescents, who rely on peer group validation and connectedness, lost a primary source of social support that made them more vulnerable to stressful circumstances. In addition, access to primary care and routine screening was reduced or limited to virtual care. A consensus panel recently issued its recommendations for in-person medical evaluation for eating disorders when needed to ensure the appropriate assessment of medical instability. 31 Reduced in-person medical assessments would likely make early detection of disordered eating more challenging and impede the early deployment of therapeutic interventions to slow or stop the progression of illness.

This study has some limitations. We were unable to make concrete causal inferences because factors other than the COVID-19 pandemic may have been associated with the increase of new-onset anorexia nervosa or atypical anorexia nervosa during the study period. Data collection occurred in 6 of the 10 pediatric tertiary eating disorder programs in Canada, spanning both coasts and including sites from the 4 most populous provinces (representing nearly 90% of the Canadian populace). However, not every province was represented, and all study sites are located in urban centers; thus, the findings may not be generalizable to all practice settings. All 6 study sites continued to see new eating disorder assessments during the first wave of the pandemic, and no site limited the number of hospitalizations. However, because of growing patient volumes, all sites shifted to prioritize the evaluation of youth with more severe presentations (eg, large amount of weight loss, substantial change in vital signs, or need for hospitalization); therefore, the possibility of selection bias cannot be excluded. Conversely, fewer youth with anorexia nervosa or atypical anorexia nervosa may have been identified and referred for assessment because of school closures, and many children and adolescents and their families may have chosen to avoid hospital centers for fear of exposure to COVID-19 infection. These factors suggest that the findings may be an underestimation of the true burden of newly diagnosed anorexia nervosa or atypical anorexia nervosa. This study only included patients who met the DSM-5 criteria for anorexia nervosa or atypical anorexia nervosa at the initial assessment and therefore does not capture the total incidence and hospitalization rates across all eating disorder diagnoses. Other centers may have reached clinical significance if all eating disorder diagnoses were included. The degree of social confinement and school closures varied temporally between provinces, with Central Canada adopting longer and stricter confinement measures during the study period. The second wave of the pandemic (September 1 to December 31, 2020), which affected provinces more uniformly, was unlikely to be captured in these results and may have had a greater impact in provinces outside of Central Canada.

In this cross-sectional study, we found an increase in the incidence and hospitalization rates of newly diagnosed anorexia nervosa or atypical anorexia nervosa in a national sample of youth during the first wave of the COVID-19 pandemic in Canada. Patients who were diagnosed in this period were more likely to present with rapidly evolving and more severe markers of disease. These findings highlight the need for expanded eating disorder and mental health programs during and after the COVID-19 pandemic. Research is still needed to better understand the drivers and prognosis for these patients and how best to prepare for their mental health needs in the event of future pandemics or prolonged social isolation.

Accepted for Publication: October 11, 2021.

Published: December 7, 2021. doi:10.1001/jamanetworkopen.2021.37395

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2021 Agostino H et al. JAMA Network Open .

Corresponding Author: Holly Agostino, MD, CM, Division of Adolescent Medicine, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, 1040 Atwater, Montreal, QC H3Z 1X3, Canada ( [email protected] ).

Author Contributions: Drs Agostino and Burstein had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Agostino, Burstein, Vyver, Dimitropoulos, Dominic.

Acquisition, analysis, or interpretation of data: Agostino, Burstein, Moubayed, Taddeo, Grady, Vyver, Dominic, Coelho.

Drafting of the manuscript: Agostino, Burstein, Grady, Vyver.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Agostino, Burstein.

Administrative, technical, or material support: Agostino, Moubayed, Taddeo, Grady, Vyver, Coelho.

Supervision: Dimitropoulos, Coelho.

Conflict of Interest Disclosures: Dr Vyver reported receiving funding from the Canadian Paediatric Surveillance Program/Public Health Agency of Canada for a surveillance study of anorexia nervosa during COVID19 outside the submitted work. No other disclosures were reported.

Funding/Support: This study received no funding. Dr Burstein was funded by a career award from the Quebec Health Research Fund. Dr Coelho was funded by an investigator award from the Michael Smith Foundation for Health Research Health Professional.

Role of the Funder/Sponsor: The Quebec Health Research Fund and the Michael Smith Foundation had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Xun Zhang, PhD, Research Institute of McGill University Health Centre, for assisting with statistical analyses. We also thank Deepika Bajaj, BA, Pei-Yoong Lam, MBBS, and Fiza Syal, BC Children’s Hospital; Gisele Marcoux, MSc, and Manya Singh, MEd, University of Calgary; Ashley Tritt, MD, Sainte Justine Hospital; and Cheryl Webb, MSW, RSW, McMaster Children’s Hospital, for assisting with data collection. These individuals received no additional compensation, outside of their usual salary, for their contributions.

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Yale Team Uncovers Promising New Therapeutic for Anorexia Nervosa

Anorexia nervosa (AN) is the deadliest psychiatric illness  aside from opioid use disorder, with scarce effective treatment options. A new study by Yale researchers reveals a potential new therapeutic for the disorder, as well as for cancer-induced anorexia and other mood disorders.

While scientists still don’t understand the molecular mechanisms that underlie anorexia, a team led by principal investigator Yingqun Huang, MD, PhD , professor of obstetrics, gynecology & reproductive sciences at Yale School of Medicine, found that a small synthetic molecule called Bobcat339 significantly weakened AN, as well as associated anxiety and depressive-like behaviors, in a mouse model, causing few side effects.

The team hopes the findings, published in Proceedings of the National Academy of Sciences , is a step toward developing new and safe therapeutics.

“This small molecule, Bobcat339, can mitigate AN in a mouse model,” says Huang. “So, we propose that it may also be effective in treating human AN and perhaps cancer-induced anorexia and associated mood disorders.”

A Surprise in the Lab Points Researchers Toward Anorexia

The discovery of Bobcat339, says Huang, was “a serendipitous thing.” She had been studying a protein called TET3, a member of the TET protein family (TET1/2/3), in the context of type 2 diabetes and found in 2020 that its expression was increased in the livers of patients with diabetes. Through delivering genetic material known as small interfering RNAs (siRNAs) that targeted TET3 specifically to the livers of mice, her team discovered that they could attenuate type 2 diabetes in animal models.

In humans, [anorexia nervosa] usually manifests during puberty, but mood problems often persist through adulthood. A similar thing happened with our mouse model. Yingqun Huang, MD, PhD

Then, Huang learned that Bobcat339 is a TET protein inhibitor. Intrigued, she hoped it might be a good molecule for treating type 2 diabetes. To her surprise, after ingesting Bobcat339 through their drinking water, the mice did not get better. “The mice began eating like crazy—hyperphagia,” says Huang. “At first, this was so disappointing.”

But the path that Bobcat339 took through the mice’s bodies led to a crucial finding. After Huang’s team fed the mice the molecule, they discovered that it also traveled to the brain, where it regulated TET3 by interacting with AgRP neurons. This group of neurons, located in the hypothalamus, plays a significant role in regulating feeding, energy expenditure, and other complex behavior including anxiety, depression, and compulsive behaviors.

“These neurons are very important not only for regulating food intake, but also mood,” says paper co-author Tamas Horvath, DVM, PhD, chair and Jean and David W. Wallace Professor of Comparative Medicine and professor of neuroscience and of obstetrics, gynecology & reproductive science.

This led to another publication , in which Huang and Horvath teams used CRISPR knockdown of TET3 specifically in AgRP neurons in mice and discovered this induced hyperphagia as well as anti-anxiety and anti-depressive effects. This sparked the teams’ interest in using Bobcat339 to knockdown TET3 and treat an entirely different condition altogether—AN.

Anorexia Damages the Body and Mind

AN is characterized by reduced food intake, low body weight, and obsessive-compulsive activity like overexercising, as well as mood disorders such as depression and anxiety. It is notoriously difficult to treat. Even after patients recover in terms of their food intake, body weight, and exercise level, mood problems often persist. The condition can be treated with psychotherapy and nutritional support, but these interventions have low efficacy and high relapse rates. There is no medication available for AN.

The activity-based anorexia model is a well-established model in which mice are kept in an apparatus with a running wheel. By withholding food from mice and only making it available for two hours a day for three days, researchers can induce anorexia behavior. The mice quickly reduce their food intake, lose body weight, and exhibit obsessive-compulsive wheel-running behavior. After three days, the researchers resume normal feeding.

Huang’s team took measurements during both the restrictive and recovery periods. Mice that were administered Bobcat339 through intraperitoneal injections showed significantly higher food intake and lower compulsive wheel running than untreated mice during the restrictive period. Upon resuming normal feeding, although mice in the untreated control group regained their body weight, they still exhibited depressive and anxious behaviors.

“In humans, AN usually manifests during puberty, but mood problems often persist through adulthood. A similar thing happened with our mouse model,” says Huang.

In contrast, mice treated with Bobcat339 showed fewer of these behaviors. “This small molecule helps mice maintain their food intake, maintain their body weight, and inhibit compulsive behaviors,” she says. “This drug is also working in mitigating anxious and depressive-like behaviors.”

The team hopes that the molecule may also be useful in treating humans struggling with anorexia nervosa, as well as those struggling with mood disorders. In contrast to typical anti-depressants, which can need weeks to take effect, Bobcat339 was found to improve problems associated with mood in as little as a day. The team also plans to conduct future studies evaluating its ability to mitigate cancer-induced anorexia and depression.

Featured in this article

• Yingqun Huang, MD, PhD Professor, Obstetrics, Gynecology & Reproductive Sciences
• Tamas Horvath, DVM, PhD Jean and David W. Wallace Professor of Comparative Medicine and Professor of Neuroscience and of Obstetrics, Gynecology, and Reproductive Sciences; Chair, Comparative Medicine

• Open access
• Published: 11 December 2023

What kind of illness is anorexia nervosa? Revisited: some preliminary thoughts to finding a cure

• S. Touyz 1 ,
• E. Bryant 1 ,
• K. M. Dann 1 ,
• J. Polivy 2 ,
• D. Le Grange 3 ,
• P. Hay 4 , 5 ,
• H. Lacey 6 ,
• P. Aouad 1 ,
• S. Barakat 1 ,
• J. Miskovic-Wheatley 1 ,
• K. Griffiths 1 ,
• B. Carroll 1 ,
• S. Calvert 7 , 8 &
• S. Maguire 1  

Journal of Eating Disorders volume  11 , Article number:  221 ( 2023 ) Cite this article

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Two decades have elapsed since our publication of ‘What kind of illness is anorexia nervosa?’. The question remains whether our understanding of anorexia nervosa and its treatment thereof has evolved over this time. The verdict is disappointing at best. Our current gold standard treatments remain over-valued and clinical outcomes are modest at best. Those in our field are haunted by the constant reminder that anorexia nervosa carries the highest mortality rate of any psychiatric disorder. This cannot continue and demands immediate action. In this essay, we tackle the myths that bedevil our field and explore a deeper phenotyping of anorexia nervosa. We argue that we can no longer declare agnostic views of the disorder or conceive treatments that are “brainless”: it is incumbent upon us to challenge the prevailing zeitgeist and reconceptualise anorexia nervosa. Here we provide a roadmap for the future.

In our essay over two decades ago, we described anorexia nervosa as follows:

“ Anorexia nervosa is a mental and physical disease that was recognised in France in the 19 th century, usurped for England by Queen Victoria’s physician, and subsequently adopted by many thousands of Americans. According to the prevailing grand narratives embodied in DSM-IV and ICD 10, it is merely a part of the spectrum of eating disorders. This categorisation not only distorts our view of the illness, but also trivialises its seriousness (Beumont and Touyz [ 1 ] ) .”

It is not difficult to be disillusioned with our current concepts of anorexia nervosa (AN). Little has changed over the past 20 years since the publication of “ What kind of illness is anorexia nervosa? ”[ 1 ]. One incontrovertible fact about AN remains—it takes time to recover [ 2 ]. Despite decades of research into psychological interventions, and to a lesser extent pharmacotherapy, AN continues to have the sad distinction of having the highest mortality rate of all of the psychiatric disorders [ 3 ]. Researchers working in illnesses such as diabetes can point to their innovation in developing GLP1 agonists [ 4 ], and those in surgery to the advances in key-hole interventions [ 5 ] to manage, and in many cases even cure, people of their condition. Contrastingly, researchers and clinicians in the field of AN must accept that only 30 percent of those who survive the illness at ten years are fully recovered [ 6 ]. Schmidt and Campbell lamented that “ AN in adulthood remains markedly persistent and difficult to treat, with the holy grail of an effective, replicable outpatient treatment remaining highly elusive ” [ 7 , 8 ]. It is fair to say this picture is somewhat more optimistic for patients who are rapidly treated in adolescence, providing this treatment is in the outpatient domain where families are actively engaged in support of the young person’s recovery. Moreover, such family-based approaches can significantly reduce the need for inpatient treatment, the latter often associated with high rates of relapse and readmission to inpatient settings [ 9 , 10 ]. A precise explication for why treatment outcome in adolescence might be more favourable than in adulthood is complex. One hypothesis to consider here is that AN presenting in early adolescence is a ‘different’ syndrome than when presenting in adulthood in that the relational processes in adolescent AN are less compromised, which in turn makes recovery more likely [ 11 ]. Schmidt and Campbell [ 6 , 7 ] also drew attention to the lack of innovation in psychosocial treatments to date and felt it to be unlikely that any future breakthroughs in treating AN would emanate out of the talking therapies alone [ 8 ]. Kaye and colleagues (2015) have rubbed further salt into the wound by declaring that the field has fallen behind other psychiatric disorders in terms of the understanding of responsible brain circuitry and pathophysiology and agree that the treatment of AN can no longer remain “brainless” [ 8 , 12 ]. Bulik has further exposed this unpalatable truth by declaring that we have ‘…. not been paddling as hard as we can’ [ 13 ]. She later went on to say that the science of eating disorders has been held back by decades of “misunderstanding and misconceptions” and that there has been an ongoing promulgation of myths pertaining not only to the aetiology of AN, but as to the clinical effectiveness of treatment, as well as the prospects for recovery/cure [ 14 ].

There has been a proliferation of eating disorders in succeeding editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). It has grown from one diagnostic group to eight, and each warrants our attention [ 15 ], all contributing significantly to the burden of disease in eating disorders. But the profound suffering of those with severe and enduring anorexia nervosa (SE-AN) as well as the heavy financial load that it places on their carers continues unabated [ 16 ].

It is perhaps tempting to focus our energy on repairing over-burdened mental healthcare systems post COVID-19; however, the more vexing challenge is perhaps addressing the deeper malady at play which lies at the root of the problem: what exactly is AN? Is it a misperception of body image as Bruch alluded to [ 17 ], or a psychotic illness? [ 18 ]. Is it a phobia of normal body weight as Crisp described? [ 19 ]. Garner and Bemis [ 20 ] drew similarities between the severe psychological and physiological symptoms of malnutrition observed in the Minnesota Starvation Study [ 21 ] with those of the emaciated patient with AN, yet refeeding to the expected body weight rarely in itself guarantees full recovery from the illness [ 22 ]. Is it a learned habit as proposed by Strober, Walsh and Steinberg, and are such habits prone to consolidation during episodes of under-nutrition? [ 7 , 23 ]. The origins of this concept can be traced back to Montaigne who summarised this phenomenon better than most:

For in truth habit is a violent and treacherous schoolmistress. She establishes in us, little by little, stealthily, the foothold of her authority; but having by this mild and humble beginning settled and planted it with the help of time, she soon uncovers to us a furious and tyrannical face against which we no longer have the liberty of even raising our eyes (Montaigne (1580), in Graybiel [ 24 ] ) .

If neurobiological mechanisms are the root cause, will newer interventions such as temperament-focussed treatments be the answer? [ 12 ]. Are there data to refute some of these early propositions which might at least open the door ever-so-slightly for a reconceptualisation of AN? [ 25 ]. The room for growing our understanding of AN is boundless, but a shift in thinking is needed.

As early as 1985, Touyz et al. showed that those with AN did not misperceive or inaccurately distort their body image, but their persistent distress regarding their body shape was an affective over-evaluation rather than a factual distortion or visual misperception [ 26 ]. Yet this over-valuation of shape and weight has become the hallmark of AN and “such enduring wrong assumptions” are now being challenged [ 27 ]. Those with lived experience have been equal in their disdain regarding the social contagion of “body image” being at the core of this devastating illness. Such simplification of the complexity of AN becomes minimising, ultimately breeds stigma and misdirects the focus of research and clinical advancement. Bryant (2021), in her Lancet Psychiatry essay, has summarised this well when she asserts that “anorexia is an illness that blurs culture and pathology, and modern medicine still does not understand it” and that “the idea that something this powerful is merely a gesture of vanity is not only laughable, it is insulting” [ 28 ].

It is important to remember here that the earliest descriptions of AN by Moreton [ 22 ], Gull [ 29 ], and Lasegue [ 30 ] did not refer to any concerns about shape or weight, and it would therefore seem that that such a depiction of this illness is perhaps a more recent development in the history of AN [ 31 ]. Consequently, it has led to speculation that there could in fact be fat or weight phobic and non-fat phobic cases of AN [ 32 , 33 ]. Moreover, in a recent published study by our group, 5 of 21 AN patients admitted to hospital had beliefs of delusional intensity rather than merely having an over-valued idea [ 34 ]. To these arguments, one must add the important contribution of the Anorexia Nervosa Genetics Initiative (ANGI) study [ 35 ], which delineated many of what might be considered core symptoms of AN, but also came to the conclusion, albeit preliminary, that it was not only a psychiatric disorder but a metabolic one as well [ 36 ].

Is weight recovery from AN equivalent to actual recovery? Our group contrasted those who had gained significant weight (and can be considered weight recovered) to those who had in fact more fully recovered on several measures (including Eating Disorders Examination score and psychosocial adjustment) [ 37 ]. There were subtle differences between these two groups, suggesting the deeper more damaging psychological roots characteristic of AN had not diminished despite significant weight gain. There is an abundance of clinical confirmation as to the veracity of this contention, in that patients often allude to profound and life-disrupting distress caused by their persistent illness whilst at exactly the same time, their caregivers and families report their relief at the weight gain [ 38 ]. Caregivers and families, together with the therapeutic team appear unable to understand the overwhelming anxiety and phobic distress at the core of their loved one’s suffering has either remained constant, or at times even become exacerbated despite significant gains in weight. In many cases, they go on to lose weight again to alleviate and communicate that distress [ 38 , 39 ]. This is not to negate that weight gain is essential for recovery in the emaciated patient with AN, but unfortunately for many, weight recovery alone is not the silver lining as the “monster within” continues unabated.

We have also referred to a biological candidate marker for AN. In her ground-breaking ERP studies, Hatch et al. [ 40 ] was able to show that emotionally elicited ERPs pertaining to facial expression did not change throughout weight gain and remained depressed relative to controls. In not too dissimilar a vein, the over-active Default Mode Network (DMN) is now being targeted in innovative studies using psilocybin assisted psychotherapy [ 41 ]. Koning and Brietzke [ 41 ] in their narrative review on the potential role of Psilocybin Assisted Psychotherapy (PAP) in eating disorders, describe a 1959 French clinical case study of a patient with treatment resistant AN who received two doses of psilocybin. This resulted in her gaining insights into the root causes of her disorder with an almost immediate improvement in mood, and longer-term weight gain. They go on to provide a cogent argument that a disturbed neurotransmitter signalling may lie at the heart of the aetiology of this disorder. There is now emerging evidence to implicate both neurostructural changes in AN as well as abnormalities in reward and somatosensory processing networks [ 42 , 43 ]. Koning and Brietzke postulate that PAP may target many of the core aspects of AN including (a) serotonergic function, (b) abnormal eating behaviours, (c) depressive symptoms, (d) cognitive flexibility, (e) anxiety, (f) distress and avoidance of feared foods, as well as (g) acceptance of weight gain [ 41 ]. Much enthusiasm abounds with regards to psychedelics in the treatment of psychiatric disorders [ 44 ], however the clinical efficacy of these treatments remains to be determined and it is unlikely to be a panacea for “all that ails”.

The outcome data of such studies are eagerly awaited as they may identify critical differences in brain function in AN. As Kaplan points out “AN hijacks the neuronal system of the brain and pathologises it” (personal communication). Williams has started to map the brain circuitry in depression which could ultimately change the clinical landscape for that illness. For example, she refers to a large biomarker prediction study that indicates amygdala hyperactivation consistent with a negative bias biotype might help to delineate those patients who are less likely to respond to alternative types of antidepressants such as a dual-action serotonin–noradrenaline reuptake inhibitor [ 45 ]. Could the brain circuitry of AN be mapped in a similar way to that of depression? Both genetic and clinical research point to an almost hatred /disavowal of self, neophobia, unimaginable anxiety, intrapersonal and interpersonal distress, perseveration and rigidity, fear of failure, maturity fears, a disconnect between perception of illness severity and even impending death and a feeling of not deserving to eat, which are stoically defended despite evidence to the contrary [ 2 ]. As stated previously, at times these reach delusional intensity.

Our current treatments either focus disproportionally on overvaluation of shape and weight or on refeeding [ 22 , 46 , 47 ]. We accept both are essential for ultimate recovery. There are many clinical examples of AN patients who attain a normal weight who show a rapid and somewhat remarkable recovery after re-engaging with life as it was prior to weight loss. However, others struggle, despite having received evidence-based interventions and go on to progress to a severe and often enduring form of this disorder. What separates out the 30 percent who recover within 10 years from the 30 percent who require 10–20 years to achieve the exact same outcome, and the 40 percent who appear to never recover or die an often-tragic early death after years of suffering, for both patient and their carers? [ 6 ]. It does not seem implausible that the lengthy delay to full recovery after more than a decade of illness may indicate the brain healing itself, but only if an optimum weight is maintained whilst at the same time challenging the debilitating symptoms of the disorder. Such brain plasticity is now well known [ 48 ]. The time may have come to embark on a harm minimisation strategy [ 49 ] using universally accepted rehabilitation concepts (e.g., supported accommodation, recreational and vocational opportunities) as has been established for schizophrenia [ 50 ]. It may well be that those with SE-AN who appear to show a remarkable recovery after years of illness are in fact those who were able to realign their disrupted neuronal system by maintaining a more optimum weight and at the same time dealing with the core psychopathological characteristics of the disorder.

With recent developments in the study of genetics and epigenetics, metabolism, neural networks and personalised medicine [ 51 ], we are at the cusp of a paradigm shift which augers well for the future. For more than a century we have created a straw house, just like the three little pigs in the well-known children’s fable. This has served its purpose until now as clinicians have an imperative to treat and individuals with AN deserve nothing less than to be offered, at least initially, an evidence-based treatment. But these treatments continue to have modest recovery rates [ 6 ] and are wearing thin despite attempts to boost their clinical efficacy. How long will it take for the big bad wolf to come along and ‘huff-and-puff and blow the house down’? Only time will tell!

What will the future look like in the brave new world of eating disorders and how will we get there? The world recently witnessed the break-neck speed with which research related to COVID-19 was translated into practice [ 5 ]. With the will and appropriate funding, change can happen swiftly. The eating disorders field needs to build on the scientific foundations laid, and in many countries there are now ground-breaking research initiatives such as government-funded centres for excellence to enable this. This will ensure a sophisticated research infrastructure and workforce at the ready for the next exciting chapter in our understanding of what eating disorders are and how they can be best treated [ 52 , 53 ].

When it comes to the oldest eating disorder in the DSM [ 15 ], anorexia nervosa, it is “groundhog day”. We need to start again. However painful this may be, it must surely be done. This is not to throw the proverbial baby out with the bathwater – much has been achieved over the past decades including important theory developments and research demonstrating the safety of rapid refeeding without the over-arching nemesis of refeeding syndrome [ 54 ], or undertaking refeeding in the home environment [ 55 ]. But the well-worn assumption that AN is essentially a phobia about body image and that refeeding to a healthy weight constitutes full recovery should be reconsidered. AN is a complex psychiatric/metabolic disorder with roots firmly entrenched in early childhood characterised by a heightened degree of anxiety, lack of reward sensitivity, the avoidance of novelty seeking and a fragile self-esteem with a desperate need for sameness [ 56 , 57 , 58 , 59 ]. A marked fear of failure, and early indications of reluctance to engage in interpersonal relationships is at times confused by the suggestion that AN is somehow implicated in Autism Spectrum Disorder (ASD)—although this is not to say that some with AN may in fact have a dual diagnosis in this regard [ 60 ].

Although the Eating Disorder Examination (EDE) [ 61 ] has become the “gold standard” in the assessment of eating disorders and has enabled a high level of comparison between published studies, it has an unfortunate bias in that it conceptualises AN as a disorder with overvaluation of weight and shape at its core. The time has arrived to better delineate the phenomenology of AN [ 58 ], and then construct targeted treatments in the true spirit of precision psychiatry. To do so, a new multiaxial assessment instrument is needed that provides a comprehensive profile of each and every patient diagnosed with AN so that the complexities inherent in each case can be better evaluated and then targeted in intervention [ 62 ].

What would such a multiaxial assessment look like? What is needed is a scale that includes a comprehensive psychological profile of the core characteristics of AN, thus eliminating the need for the commonly used psychometric instruments such as the DASS, Beck Depression or Anxiety inventories, WSAS [ 63 , 64 , 65 , 66 ], self -esteem measures, perfectionism inventories, quality of life measures, to name just a few. We began this work developing the first co-designed (before the concept was fashioned) deep multi-axial assessment purely designed to measure the core psychological features of anorexia nervosa and assess their manifestation along severity axes providing a deeper understanding of the phenotype (the CASIAN; [ 67 , 68 ]. This work needs to be extended and broadened to include other parameters, although the second axis could measure the stage of illness as the illness changes with regards to severity over time [ 69 ]. The third axis may include the laboratory investigations routinely administered such as bloods, biochemistry, liver function, ECG and bone densitometry scans. A fourth axis could include brain circuitry based upon EEG and fMRI analyses. A biological candidate marker for AN already exists [ 40 ], and as this rapidly evolving phase of discovery gains momentum, this axis will come into its own. A further axis should provide a comprehensive neuropsychological profile based upon well-established research criteria developed by Tchanturia et al. and others [ 70 , 71 ]. Lastly, an additional axis devoted to functional outcomes is warranted. Improvements in everyday functioning are meaningful treatment outcomes for patients [ 72 ], and despite current illness, AN patients have enduring functional strengths which could be integrated into treatment [ 73 ]. What is so remarkable about AN is the oft-observed degree of resilience when it comes to academic achievement, or the ability to outperform others in a scholastic or work environment. This phenomenon has been noted in the genetic studies undertaken thus far [ 36 ], and although perfectionistic and maladaptive because of its extremes, does offer a strength to be better utilised in therapy.

Finally, the subtyping of restrictive versus binge/purge AN, which has been integral to each and every DSM iteration, may have reached its used-by-date. Although somewhat diligently recorded in almost every published study, and if not provided then without doubt would be requested during the review process, this distinction adds little to overall clinical care. Pierre Beumont was not only one of the founding fathers in the field of eating disorders, but a visionary scientist as well. While he was the first to point to the heterogeneity of AN and the need to subtype the disorder [ 74 ], a new subtyping is proposed here similar to an early model of depression [ 75 ]. A novel subtyping of reactive versus endogenous AN needs scientific exploration (Polivy, 2023 personal communication). It is proposed that in those patients with AN, where a clear precipitant is able to be identified (Reactive AN), existing evidenced-based treatments may be clinically effective; but, perhaps less so for those who have a more endogenous onset without an obvious precipitating factor or event (Endogenous AN). Patients with more complex presentations also appear less likely to respond to talk therapies, and may need a different, possibly more biological, approach. It is the latter group to whom the term “treatment resistant” is likely to be applied, with blame often attributed to the person with the illness. It is, however, the therapist who might be inadequate here, as the existing (psychological) treatments may not have the clinical power to effect change in this seriously ill and distressed cohort.

We cannot deny the indisputable fact that patients with AN continue to suffer (many for years and even decades) and die from this serious disorder. Patients in continental Europe have been approved for euthanasia and reports on “palliative care” are increasing. The desperate need to avoid further suffering is often openly expressed by those with a lived experience and their carers alike. However, others have expressed caution— asserting that in the absence of a clinically effective evidence-based treatment, it is unwise to talk about someone being treatment resistant, and further, that many patients with AN either receive no treatment at all − or at best inadequate treatment. Are these the advances we desperately wanted in our field in 2023? We suspect not. The time for complacency has ended and the need to find a cure for AN has arrived. We have brilliant minds at work, but rather than working in silos we need to work together with colleagues not just from inside our field, but also from outside our immediate field to finally put the conundrum of AN to rest. Bulik has likened the field of eating disorders to an island, suggesting we have not been “gregarious enough in engaging external scientists in our work” [ 14 ]. We also need to find ways to overcome the issue of under-funding in eating disorder research that contribute to the maintenance of the status quo [ 76 , 77 ]. It is now almost a century and a half since Gull [ 29 ] described AN, and those enduring the illness and their carers cannot wait any longer. We owe it to them.

So, what might the treatment of AN look like in a decade’s time? Kan and colleagues have given us a glimpse into the futuristic world of AN treatment and a possible roadmap to get there [ 51 ]. They provide a cogent argument that the time has now arrived to focus our research initiatives on developing new interventions that reduce the translational gap between emerging findings in neuroscience and the clinic. The days of agnostic assumptions in this regard are numbered.

Thus, we may need to tailor treatment and supplement intervention by targeting specific elements of risk and resilience. This would require a deeper phenotyping to examine facets of the core psychopathology including social and interpersonal function, reward reinforcement, anxiety sensitivity, cognitive styles and other biomarkers [ 51 ].

We encourage others to build upon this model or to provide alternative ones. Fernandez-Aranda and colleagues have already reminded us that “necessity is the mother of invention” and the aftermath of COVID 19 will no doubt lead to changes in our therapeutic models with the introduction of “more efficient and effective mixed methods of connection and a more personalized treatment palette as to what and how might work best for whom” [ 78 ].

So, what might the smorgasbord of innovative treatment modalities look like in the AN clinic of the future? Both Treasure et al. and Stengel and Giel have already begun to explore “emerging therapeutic targets” that could provide the armamentarium for treatment delivery in the next decade [ 79 , 80 ]. These will not only include the eating disorder phenotype such as cognitive, social and emotional difficulties, but also compounds other than olanzapine and antidepressants. The list grows longer day by day with further interest in lithium, ketamine, psilocybin, opioids, endocannabinoids as well as hormones such as oestrogen, histamine, oxytocin, leptin, growth hormone, ghrelin and nesfatin-1 [ 81 ]. These could be supported by innovations that better target eating behaviour habits and underlying processes that focus particular attention on implementation interventions, exposure-based therapies, inhibition training as well as disruptions to food cravings. Furthermore, neuromodulatory treatments that include non-invasive brain stimulation (NIBS) and deep brain stimulation (DBS) are being actively explored, however, caution should be exercised before we rush into interventions based on preliminary hypotheses or limited evidence. Further systematic research will be needed to determine the ultimate clinical success of these novel treatments, which must also be balanced by the risk of doing harm and making sure to adhere to the first rule in medicine “primum non nocere”.

Co-design is the new mantra of the day but rarely is it implemented in the manner that it was advocated and unfortunately tokenism abounds. Stengel and Giel so aptly point out that if our desired aim is to increase the acceptability and eventual adoption of novel therapeutics then “… it will be an important next step to increase integration of lived experience by patients and carers into the whole clinical research process” [ 80 ]. The status quo can no longer prevail. Science does not take kindly to attempts to change the existing zeitgeist but there now appears to be an unstoppable groundswell and determination to do exactly that in both our understanding and delivery of efficacious treatment(s) in AN. Existing clinical guidelines will become increasingly challenged and much careful thought and deliberation will need to be given to future iterations of DSM and ICD as the avalanche of new and exciting research findings come into play.

It is not expected that those who read this commentary will agree with all the propositions enunciated above, but it is hoped that it may spur others to action as it is likely to be a collective enterprise that ultimately bears the fruit of success. [ 16 ]. Opportunities for increasing research spending and providing opportunities for cross-collaborative research will go some way to enhancing translational research in the eating disorder field. However, any such enterprise must embrace the views of those with lived experience and their carers. They know better than most as to what this “monster within” does to often brilliant minds. We should refrain from our well-worn mantra of improving clinical effectiveness to the much loftier aspiration of finding a cure for AN. It is now within our grasp and time is of the essence. This journey has already commenced and the quotation from Noam Chomsky below should provide further impetus to realise this lofty aim.

“Optimism is a strategy for making a better future. Because unless you believe that the future can be better, it's unlikely you will step up and take responsibility for making it so. If you assume that there's no hope, you guarantee that there will be no hope.”—Noam Chomsky

Availability of data and materials

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Acknowledgements

We would like to thank all those with lived experience who have shaped our understanding of this often-devastating illness. S.T. would like to acknowledge the important role that the late Pierre Beumont played in developing an understanding of AN. He was my mentor, colleague and friend and is sorely missed. We would also like to thank the anonymous reviewers for contributing their improvements to the manuscript.

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Translational Health Research Institute, School of Medicine, Western Sydney University, Campbelltown, Australia

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ST: conceptualization, writing—original draft. EB and KD: writing—original draft, writing—review and editing and project administration. JP, DLG, PH, HL, PA, SB, JMW, KG, BC, SC: writing—review and editing. SM: writing—review and editing, and supervision. All authors contributed to the article and approved the submitted version.

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P.H. has received sessional fees and lecture fees from the Australian Medical Council, Therapeutic Guidelines publication, and New South Wales Institute of Psychiatry and royalties from Hogrefe and Huber, McGraw Hill Education, and Blackwell Scientific Publications, and she has received research grants from the NHMRC and ARC. She is Chair of the National Eating Disorders Collaboration in Australia (2019–) and an Editor in Chief of this journal. In July 2017, she provided a commissioned report for Takeda (formerly Shire) Pharmaceuticals on lisdexamfetamine and binge eating disorder, is a consultant to Takeda, and in 2018–2020 received honoraria for education of Psychiatrists. S.T. receives royalties from Taylor and Francis, Hogrefe and Huber and McGraw Hill for published book chapters. He has received honoraria from Shire/ Takeda Group of Companies for chairing the Australian Clinical Advisory Board for Binge Eating Disorder, public speaking engagements, commissioned reports as well as investigator- initiated research grants. He is an Editor in Chief of this journal, an inaugural committee member of the National Eating Disorders Collaboration, a Member of the Technical Advisory Group (TAG) on Eating Disorders (Commonwealth of Australia) and a member of the governing council of the Australian Eating Disorders Research and Translation Centre. DLG receives royalties from Guilford Press and Routledge, is Co-Director of the Training Institute for Child and Adolescent Eating Disorders, LLC, and is a member of Equip Health Clinical Advisory Board. The other authors have no conflicts of interest to disclose.

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Touyz, S., Bryant, E., Dann, K.M. et al. What kind of illness is anorexia nervosa? Revisited: some preliminary thoughts to finding a cure. J Eat Disord 11 , 221 (2023). https://doi.org/10.1186/s40337-023-00944-3

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2020 Breakthrough Research in Anorexia Nervosa: Drs. Cynthia Bulik and Walter Kaye

Anorexia Nervosa (AN) is a puzzle for many reasons. What is it, and what can we do to treat it are commonly asked questions by students and health professionals alike? While we do not have a blood or other test to make a diagnosis, the combination of signs and symptoms are classic and are virtually identical to those seen centuries ago.

AN was the same in 1689 as it was in 1873 as it was in 1983 when Karen Carpenter died of this disease [1]. It is the same today. AN appears to be a biopsychosocial determined disease with important genetic and neurobiological roots.

Anorexia Nervosa occurred as part of religious fasting dating from the Hellenistic era. Mary, Queen of Scots, among others, appears to have suffered from AN. The English physician Richard Morton described AN in 1689, but the medical profession did not consider it seriously until the late 19th century.

In 1873, Queen Victoria’s physicians, Sir William Gull, published the classic, seminal paper which established the term anorexia nervosa. He described cases and treatments. In the same year, French physician Ernest-Charles Lasègue similarly published details of several cases in a paper entitled De l’Anorexie Hystérique.

In an addendum to his Anorexia Nervosa paper, Sir William Gull provides the following comment on Lasègue’s work: “It is understandable that Dr. Lasègue and I have the same sickness in mind, though the forms of our illustrations are different.

Dr. Lasègue does not refer to my address at Oxford, and it is most likely he knew nothing of it. There is, therefore, the more value in his paper, as our observations have been made independently. We have both chosen the same expression to characterize the malady.

In the address at Oxford, I used the term Apepsia hysterica, but before seeing Dr. Lasègue’s paper, it had equally occurred to me that Anorexia would be more correct ” [2]. Still, awareness of AN limited to MDs until the latter part of the 20th century, when German-American psychoanalyst Hilde Bruch published her famous work “The Golden Cage: the Enigma of Anorexia Nervosa” in 1978.

Anorexia Nervosa

The National Eating Disorders Association (NEDA) estimates that between 0.3 and 0.4 percent of all young women and 0.1 percent of young men suffer from AN on this or any day. They estimate that approximately 1 percent of women and 0.3 percent of men reported Anorexia during their lifetimes.

AN is a major cause of death among adolescents and young adults. Young people between the ages of 15 and 24 with AN are estimated to be at ten times greater risk of dying compared to same-aged peers. Although the disorder also affects males, the overwhelming predominance of women is undeniable.

Bulik has led many of the recent efforts. Bulik and her collaborators have a long history of reporting new data, which is really significant progress in AN genetic research. Most recently, with her collaborators, in Nature Genetics [3].

Quick Summary-Review of AN

Mitchell & Peterson’s 2020 review in the New England Journal of Medicine [4] reminds us that AN is often fatal. About 10% of those patients with Anorexia Nervosa will die of the disease. Medical complications, suicide, and co-occurring substance use disorders (SUD) are all too commonly reported.

• Anorexia nervosa is a severe, sometimes fatal, psychiatric disorder characterized by starvation and malnutrition
• Weight preoccupation, overvaluation, and dissatisfaction are related to eating disorders, but no one body image construct can capture clinical risk in eating disorders.
• Preoccupation is the best-studied, most consistent concurrent and longitudinal predictor
• Coexisting psychiatric conditions often accompany Anorexia Nervosa
• AN is a disease that is usually progressive, difficult to treat with episodes where there is no response to treatment, frequent medical complications, and a substantial risk of death.
• Anorexia nervosa has two subtypes, but can progress from one sub-type to another: binge eating, purging, or both, and food restricting only
• AN patients are often hospitalized, which can be life-saving as they have severe starvation, dehydration hypotension, electrolyte abnormalities, arrhythmias or severe bradycardia, suicide risk. Just having a body-mass index (the weight in kilograms divided by the square of the height in meters) of 15 or less is a significant concern.
• Several psychotherapeutic approaches are commonly used in treatment by psychologists and psychiatrists
• Psychotropic medications are generally ineffective in promoting weight gain, reducing depressive symptoms, or preventing relapse in patients with anorexia nervosa.
• While current treatment is psychological and not personalized or informed by genes or improved by medications, about half of adolescents recover, and another 30% significantly improve

Scientific Progress: 2020

New insights will eventually lead to new treatments . Medications, psychedelic medicine, and deep brain stimulation may offer hope and help us to understand which diseases are the most like Anorexia Nervosa, major depression, OCD, or SUDs.

Scientific progress seen in the rest of psychiatry is finding its way to Anorexia Nervosa. The more researchers look into this disease, the more it appears to have important genetic and neurobiological causes. The circuitry of the brain’s reward system behaves differently in unaffected volunteers than in people with Anorexia and those who have recovered.

We have studied eating, eating sugar, and compared food and sugar rewards to those naturally occurring species survival reinforcement [5]. Hunger drives a search for food, eating, and makes food more rewarding. This is a well-known fact because starvation activates brain circuits that motivate eating.

One group of women had been diagnosed with AN, but were in remission (RAN); the other group did not have AN. The RAN group showed reduced neural activation to taste stimulation in the brain’s anterior insula and reduced connectivity between the right anterior and mid-dorsal insula and ventral caudal putamen.

This circuitry involves connected regions that are important for recognizing the feeling of hunger. This circuit typically would drive us to want to eat when we are starving or deprived of food. Most people report that hunger increases the reward and pleasure of food, and thus drives the motivation to eat.

Individuals with AN, however, tend to have a disconnect in this process. Anorexia Nervosa patients are obsessed with food, yet do not eat. Failure to launch this food reward circuit in people with AN may be a key to AN restrictive eating and severe weight loss in persons.

Anorexia Nervosa may be a disease where perceptions of hunger persist in a vacuum disconnected the motivation to eat. Patients with AN describe increased discomfort, anxiety, and panic when they eat, even when they are starving. Profound anxiety may contribute to starvation because it impairs the ability to start eating.

Bulik and others published in Nature Genetics the most extensive genetics study on the disease, analyzing the genomes of nearly 17,000 people with Anorexia and more than 55,000 people without. Eight risk loci for anorexia nervosa were identified that were predictive of other psychiatric disorders, a low BMI, and metabolic derangement.

This study showed that there was also a link to the ability to metabolize fats and sugars [7]. Who knows what this means other than the metabolic problems in AN could be produced by a biological predisposition.

Researchers identified other patterns of genetic associations similar to those found in other psychiatric illnesses, including OCD and depression. We had suspected that the brain’s reinforcement systems might reinforce disordered eating very early on and thought similarities to substance use disorders might offer a clue and endogenous opioid-dopamine targets.

There may be genetic and risk profile similarities between Anorexia and Bulimia Nervosa [8], which relate to genetics, reward deficiency, and early bad learning. Early starvation or dieting might be a trigger like teen cigarette smoking, early-onset binge drinking, or illicit drug use triggers .

Concluding Remarks

Psychedelic medicine [9] trials are also underway for mescaline, psilocybin, nitrous oxide, and others for depression and PTSD. Treatments for SUDs have changed dramatically over this time as well.

Reward deficiency syndrome [10] has been proposed to explain some of the patients with SUDs and brain circuits involved in naturally occurring pleasure and SUD related hijacking. Animal models for SUD have been quite good at predicting treatments, and many are currently in use. TMS [11], DBS [12], and even Vaccines based on these models may be the next for SUDs.

Many of these novel treatment approaches may be helpful in Anorexia Nervosa, Bulimia Nervosa , and other eating disorders.

1. https://www.npr.org/2013/02/04/171080334/remembering-karen-carpenter-30-years-later

2. https://en.wikipedia.org/wiki/History_of_anorexia_nervosa

3. Watson, H.J., Yilmaz, Z., Thornton, L.M. et al. Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa. Nat Genet 51, 1207–1214 (2019). https://doi.org/10.1038/s41588-019-0439-2

4. Mitchell JE, Peterson CB. Anorexia Nervosa.N Engl J Med. 2020 Apr 2;382(14):1343-1351. doi: 10.1056/NEJMcp1803175

5. Murray S, Tulloch A, Gold MS, Avena NM Hormonal and neural mechanisms of food reward, eating behaviour and obesity. Nat Rev Endocrinol. 2014 Sep;10(9):540-52. doi: 10.1038/nrendo.2014.91. Epub 2014 Jun 24.

6. Kaye WH, Wierenga CE, Bischoff-Grethe A, Berner LA, Ely AV, Bailer UF, Paulus MP, Fudge JL. Neural Insensitivity to the Effects of Hunger in Women Remitted From Anorexia Nervosa. Am J Psychiatry. 2020 Mar 12

7. Watson, H.J., Yilmaz, Z., Thornton, L.M. et al. Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa. Nat Genet 51, 1207–1214 (2019). https://doi.org/10.1038/s41588-019-0439-2

8. Yao, S., Larsson, H., Norring, C., Birgegård, A., Lichtenstein, P., DʼOnofrio, B., . . . Kuja-Halkola, R. (2019). Genetic and environmental contributions to diagnostic fluctuation in anorexia nervosa and bulimia nervosa. Psychological Medicine, 1-8. doi:10.1017/S0033291719002976

9. https://www.jns-journal.com/article/S0022-510X(20)30051-4/fulltext Chi T, Gold JA. A review of emerging therapeutic potential of psychedelic drugs in the treatment of psychiatric illnesses. J Neurol Sci. 2020 Apr 15;411:116715. doi: 10.1016/j.jns.2020

10. Blum K, Baron D, McLaughlin T, Gold MS.Molecular neurological correlates of endorphinergic/dopaminergic mechanisms in reward circuitry linked to endorphinergic deficiency syndrome (EDS). J Neurol Sci. 2020 Apr 15;411:116733. doi: 10.1016/j.jns.2020.116733. Epub 2020 Feb 14

11. https://niaaa.scienceblog.com/67/rehabilitating-the-addicted-brain-with-transcranial-magnetic-stimulation/

12. https://www.sciencealert.com/surgeon-attempting-deep-brain-stimulation-as-last-resort-for-opioid-addict

About the Author:

Dr. Gold was the first Faculty from the College of Medicine to be selected as a University-wide Distinguished Alumni Professor and served as the 17th University of Florida’s Distinguished Alumni Professor. Learn more about Mark S. Gold, MD

The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer a discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help .

Published on May 7, 2020. Reviewed & Approved on May 7, 2020, by Jacquelyn Ekern MS, LPC

Published on EatingDisorderHope.com

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Do You Have An Eating Disorder?

Do you have an eating disorder take this online quiz.

Take this quiz to help you decide whether or not you need to seek professional advice or treatment for an eating disorder.

Answer some general questions about how you feel about food, your current eating habits, how you feel after you eat, and other indicators of an eating disorder.

NOTE : This quiz is for general informational purposes only and does not, and is not intended to, constitute medical advice. The quiz is not an attempt to practice medicine and is not a substitute for professional medical advice, diagnosis, or treatment. If you have or suspect you may have a health problem, talk to your healthcare provider and follow their advice regardless of any result you have obtained on this quiz. The quiz does not establish a doctor-patient relationship.

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Recent advances in understanding anorexia nervosa

Affiliations.

• 1 Department of Psychiatry, University of Colorado, Anschutz Medical Campus, Aurora, CO, 80045, USA.
• 2 Neuroscience Program, University of Colorado, Anschutz Medical Campus, Aurora, CO, 80045, USA.
• PMID: 31069054
• PMCID: PMC6480957
• DOI: 10.12688/f1000research.17789.1

Anorexia nervosa is a complex psychiatric illness associated with food restriction and high mortality. Recent brain research in adolescents and adults with anorexia nervosa has used larger sample sizes compared with earlier studies and tasks that test specific brain circuits. Those studies have produced more robust results and advanced our knowledge of underlying biological mechanisms that may contribute to the development and maintenance of anorexia nervosa. It is now recognized that malnutrition and dehydration lead to dynamic changes in brain structure across the brain, which normalize with weight restoration. Some structural alterations could be trait factors but require replication. Functional brain imaging and behavioral studies have implicated learning-related brain circuits that may contribute to food restriction in anorexia nervosa. Most notably, those circuits involve striatal, insular, and frontal cortical regions that drive learning from reward and punishment, as well as habit learning. Disturbances in those circuits may lead to a vicious cycle that hampers recovery. Other studies have started to explore the neurobiology of interoception or social interaction and whether the connectivity between brain regions is altered in anorexia nervosa. All together, these studies build upon earlier research that indicated neurotransmitter abnormalities in anorexia nervosa and help us develop models of a distinct neurobiology that underlies anorexia nervosa.

Keywords: Anorexia nervosa; behavior; brain; brain imaging; function; habit; learning; reward; structure.

Publication types

• Research Support, N.I.H., Extramural
• Anorexia Nervosa / physiopathology*
• Body Weight
• Brain / pathology*
• Dehydration / complications
• Malnutrition / complications
• Neuroimaging
• Neurotransmitter Agents

Grants and funding

• T32 NS099042/NS/NINDS NIH HHS/United States
• T32 HD041697/HD/NICHD NIH HHS/United States
• TL1 TR001081/TR/NCATS NIH HHS/United States

Eating Disorder Research News

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• Accessibility
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Oxford Brain-Body Research into Eating Disorders

• [email protected]

Quick Facts

Founded in 2010

Novel integrative approach of clinical- neuroscience collaborations

Funding from HEFCE, MRC, Sir Jules Thorne Charitable Trust, Charles Wolfson Charitable Trust, Swiss Anorexia Foundation, Placito Bequest

We work to understand the cognitive, biological, emotional and somatic processes underpinning the severe eating disorder Anorexia Nervosa in particular, and Eating Disorders in general. Our trans-disciplinary research, involving clinicians and neuroscientists, aims to translate research findings into novel treatment strategies.

Our work focuses on Anorexia Nervosa , a severe eating disorder, which has the highest mortality rate of any psychiatric disorder. It  remains one of the most challenging to treat and recover from, with a lack of evidence-based treatments. We aim to develop more effective treatments we need a better understanding of processes underpinning the illness.

We are proud of the innovative way our research brings together cognitive science, neuroscience and experimental psychology. This integration helps generate a deeper understanding of how cognitive, emotional and bodily processes interact to maintain the illness. With an international reputation in the field of Eating Disorders, we  have made important advances in understanding the neurobiology of Anorexia Nervosa using functional magnetic resonance imaging, fMRI and MEG. These findings not only help us to better understand the disorder but enable us to push forward with research that is directly relevant to the development of new treatments.

Collaboration

In collaboration with world-class neuroscientists our work investigates brain processes underpinning thinking, feeling and experiencing reward, and how these differ for people with Anorexia Nervosa. Recent research has focused on the role of ruminative thought processes,  abnormal reward processing and compulsivity. We hope to translate research findings into developing new forms of treatment and relapse prevention.

Multimodal Imaging

In  collaboration with Professor Tipu Aziz, the Nuffield Department of Surgery, the Wellcome Centre for Ethics and Humanities and  the Oxford Centre for Human Brain Activity allowed us to initiate complimentary multimodal imaging studies of neural processing and reward in individuals with current and past Anorexia Nervosa, now published.

Deep Brain Stimulation

We also developed the first registered UK study of Deep Brain Stimulation (DBS) targeted at neural reward centres, for individuals with severe enduring Anorexia Nervosa, with full HRA approval. These studies explored the neural processing and behavioural correlates of aberrant reward and habit formation in Anorexia Nervosa, and importantly to set the worlds first  ethical  gold standard to guide experimental brain research in  Anorexia nervosa. The findings will contribute to  an understanding of the neural processes underpinning Anorexia Nervosa and in tandem develop novel treatment strategies. With the aid of additional grants and generous charitable donations we continue with DBS study, which is now in the follow-up phase. We have now published the protocol and an important ethics gold standard to guide such studies worldwide.

Affiliated groups:

OxBREaD benefits from affiliations with HBA  well established groups within the Department of Psychiatry:

Wellcome Centre for Integrative Neuroimaging, OHBA

Wellcome Centre for ethics and humanities :  Professor Ilina Singh

CREDO1 : Professor Chris Fairburn’s research group is world leading in the development of treatments for Eating Disorders.

PERL : Professors Catherine Harmer's group has an international reputation for excellence in the field of neuroscience and neuroimaging.

Rebecca Park

Associate Professor and Honorary Consultant Psychiatrist

Selected publications

Journal article

Tsompanaki E. et al, (2024), Contemp Clin Trials

Pike AC. et al, (2023), Transl Psychiatry, 13

Martens MA. et al, (2022), J Psychopharmacol

SCAIFE J. et al, (2022), Frontiers in Behavioral Neuroscience

Braeutigam S. et al, (2022), Front Behav Neurosci, 16

Interested in helping eating disorder research?

Do join our research interested list if you have any personal experience of an eating disorder, currently or in the past; or if you would be keen to participate in future research studies on eating disorders . Please contact us if you want to know more about our work, and we will then send you information. 

Email: [email protected]  

Do check out our new papers in the 'selected publications' section of this page!

In memoriam

We are deeply grateful for the recent donations from the family and friends of the late Emma Bruce. We never met Emma but she had suffered from Anorexia for many years, and not long before she died, she was given hope after hearing about the work of OxBREaD.

Current collaborations

• Professor Phil Cowen (Neurosciences, Oxford University)
• Professor Catherine Harmer (Neurosciences, Oxford University)
• Professor Kia Nobre (OHBA, Oxford University)
• Professor Tipu Aziz  (Department of Neurosurgery, Oxford University),
• Dr Jacinta Tan, Psychiatrist and ethicist, (University of Swansea)
• Dr Sanne de Witt (University of Amsterdam),
• Dr Claire Gillan (Trinity College Dublin) 

We are not currently recruiting. 

Related research themes

Melbourne researchers lead two groundbreaking anorexia treatments

Australian researchers are leading two groundbreaking trial treatments for anorexia nervosa in Melbourne.

Both trials will be led by researchers from HER Centre Australia's Li Transformative Hub for Research Into Eating Disorders (Li-THRED) at Monash University and Alfred Health.

In a randomised Australian-first trial, patients will be given transdermal estrogen patches to investigate the effects the hormone has on symptoms of anorexia.

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The trial will focus on 50 women aged 16 and over with anorexia, with researchers administering 50mcg of estradiol, the body's most potent form of estrogen, through patches. 

Placebo patches will also be used to compare the results.

Consultant psychiatrist and Li-THRED team researcher Dr Romi Goldschlager said fluctuations in estrogen have previously been linked to anorexia symptoms.

"It's more about the fluctuations and changes rather than underlying deficiency – steady and constant rather than peaks and troughs," Goldschlager said.

"My hope is that this hormone therapy will be successful in treating anorexia nervosa, a really severe illness that currently doesn't have a treatment."

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In a second trial, transcranial magnetic stimulation (TMS) will be used to apply electromagnetic stimulation to a brain network found by researchers that appears to cause anorexia.

Lead investigator, Dr Leo Chen from Monash University and Alfred Health, said his team will identify the network in each participant's MRI scans to find a target for the TMS treatment.

"With our colleagues at Brigham and Harvard, we have identified a causal brain network for anorexia behaviours," Chen said.

"We can see this network on each individual's MRI scans and will use it to identify their personalised stimulation target.

"Our hypothesis is that, using TMS, we can facilitate healthy brain cell firing and signal transmission along this network.

"In turn, we hope to improve the psychological and behavioural challenges experienced by people living with this disorder."

Anorexia nervosa is a psychiatric eating disorder that has the highest rate of mortality compared to any other psychological condition.

People with the disorder are estimated to have a death rate four times higher than those with clinical depression. 

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Butterfly Foundation spokesperson Sarah Cox said the eating disorder charity supports the clinical trials.

"It is a very complex and severe mental illness - finding the right treatment can be difficult," Cox said.

"We know that not every treatment suits every person and so having more evidence-based options into the pool of options can just be really valuable for people.

"We also know particularly with anorexia and other eating disorders there is a really strong biological component and ... so a treatment like this that directly targets the physiological and biological aspects I think can hold a lot of hope."

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Eating Disorders

What are eating disorders.

There is a commonly held misconception that eating disorders are a lifestyle choice. Eating disorders are actually serious and often fatal illnesses that are associated with severe disturbances in people’s eating behaviors and related thoughts and emotions. Preoccupation with food, body weight, and shape may also signal an eating disorder. Common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder.

What are the signs and symptoms of eating disorders?

Anorexia nervosa.

Anorexia nervosa is a condition where people avoid food, severely restrict food, or eat very small quantities of only certain foods. They also may weigh themselves repeatedly. Even when dangerously underweight, they may see themselves as overweight.

There are two subtypes of anorexia nervosa: a "restrictive "  subtype and a "binge-purge " subtype.

• In the restrictive subtype of anorexia nervosa, people severely limit the amount and type of food they consume.
• In the binge-purge  subtype of anorexia nervosa, people also greatly restrict the amount and type of food they consume. In addition, they may have binge-eating and purging episodes—eating large amounts of food in a short time followed by vomiting or using laxatives or diuretics to get rid of what was consumed.

Anorexia nervosa can be fatal. It has an extremely high death (mortality) rate compared with other mental disorders. People with anorexia are at risk of dying from medical complications associated with starvation. Suicide is the second leading cause of death for people diagnosed with anorexia nervosa.

If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide & Crisis Lifeline   at 988 or chat at 988lifeline.org   . In life-threatening situations, call 911.

Symptoms include:

• Extremely restricted eating
• Extreme thinness (emaciation)
• A relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight
• Intense fear of gaining weight
• Distorted body image, a self-esteem that is heavily influenced by perceptions of body weight and shape, or a denial of the seriousness of low body weight

Other symptoms may develop over time, including:

• Thinning of the bones (osteopenia or osteoporosis)
• Mild anemia and muscle wasting and weakness
• Brittle hair and nails
• Dry and yellowish skin
• Growth of fine hair all over the body (lanugo)
• Severe constipation
• Low blood pressure
• Slowed breathing and pulse
• Damage to the structure and function of the heart
• Brain damage
• Multiorgan failure
• Drop in internal body temperature, causing a person to feel cold all the time
• Lethargy, sluggishness, or feeling tired all the time
• Infertility

Bulimia nervosa

Bulimia nervosa is a condition where people have recurrent and frequent episodes of eating unusually large amounts of food and feeling a lack of control over these episodes. This binge-eating is followed by behavior that compensates for the overeating such as forced vomiting, excessive use of laxatives or diuretics, fasting, excessive exercise, or a combination of these behaviors. People with bulimia nervosa may be slightly underweight, normal weight, or over overweight.

• Chronically inflamed and sore throat
• Swollen salivary glands in the neck and jaw area
• Worn tooth enamel and increasingly sensitive and decaying teeth as a result of exposure to stomach acid
• Acid reflux disorder and other gastrointestinal problems
• Intestinal distress and irritation from laxative abuse
• Severe dehydration from purging of fluids
• Electrolyte imbalance (too low or too high levels of sodium, calcium, potassium, and other minerals) which can lead to stroke or heart attack

Binge-eating disorder

Binge-eating disorder is a condition where people lose control over their eating and have reoccurring episodes of eating unusually large amounts of food. Unlike bulimia nervosa, periods of binge-eating are not followed by purging, excessive exercise, or fasting. As a result, people with binge-eating disorder often are overweight or obese. Binge-eating disorder is the most common eating disorder in the U.S.

• Eating unusually large amounts of food in a specific amount of time, such as a 2-hour period
• Eating even when you're full or not hungry
• Eating fast during binge episodes
• Eating until you're uncomfortably full
• Eating alone or in secret to avoid embarrassment
• Feeling distressed, ashamed, or guilty about your eating
• Frequently dieting, possibly without weight loss

Avoidant restrictive food intake disorder

Avoidant restrictive food intake disorder (ARFID), previously known as selective eating disorder, is a condition where people limit the amount or type of food eaten. Unlike anorexia nervosa, people with ARFID do not have a distorted body image or extreme fear of gaining weight. ARFID is most common in middle childhood and usually has an earlier onset than other eating disorders. Many children go through phases of picky eating, but a child with ARFID does not eat enough calories to grow and develop properly, and an adult with ARFID does not eat enough calories to maintain basic body function.

• Dramatic restriction of types or amount of food eaten
• Lack of appetite or interest in food
• Dramatic weight loss
• Upset stomach, abdominal pain, or other gastrointestinal issues with no other known cause
• Limited range of preferred foods that becomes even more limited (“picky eating” that gets progressively worse)

What are the risk factors for eating disorders?

Eating disorders can affect people of all ages, racial/ethnic backgrounds, body weights, and genders. Eating disorders frequently appear during the teen years or young adulthood but may also develop during childhood or later in life.

Researchers are finding that eating disorders are caused by a complex interaction of genetic, biological, behavioral, psychological, and social factors. Researchers are using the latest technology and science to better understand eating disorders.

One approach involves the study of human genes. Eating disorders run in families. Researchers are working to identify DNA variations that are linked to the increased risk of developing eating disorders.

Brain imaging studies are also providing a better understanding of eating disorders. For example, researchers have found differences in patterns of brain activity in women with eating disorders in comparison with healthy women. This kind of research can help guide the development of new means of diagnosis and treatment of eating disorders.

How are eating disorders treated?

It is important to seek treatment early for eating disorders. People with eating disorders are at higher risk for suicide and medical complications. People with eating disorders can often have other mental disorders (such as depression or anxiety) or problems with substance use. Complete recovery is possible.

Treatment plans are tailored to individual needs and may include one or more of the following:

• Individual, group, and/or family psychotherapy
• Medical care and monitoring
• Nutritional counseling
• Medications

Psychotherapies

Family-based therapy, a type of psychotherapy where parents of adolescents with anorexia nervosa assume responsibility for feeding their child, appears to be very effective in helping people gain weight and improve eating habits and moods.

To reduce or eliminate binge-eating and purging behaviors, people may undergo cognitive behavioral therapy (CBT), which is another type of psychotherapy that helps a person learn how to identify distorted or unhelpful thinking patterns and recognize and change inaccurate beliefs.

Evidence also suggests that medications such as antidepressants, antipsychotics, or mood stabilizers may also be helpful for treating eating disorders and other co-occurring illnesses such as anxiety or depression. The Food and Drug Administration’s (FDA) website  has the latest information on medication approvals, warnings, and patient information guides.

How can I find a clinical trial for an eating disorder?

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy volunteers. We have new and better treatment options today because of what clinical trials uncovered years ago. Be part of tomorrow’s medical breakthroughs. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you.

To learn more or find a study, visit:

• NIMH’s Clinical Trials webpage : Information about participating in clinical trials
• Clinicaltrials.gov: Current Studies on Eating Disorders  : List of clinical trials funded by the National Institutes of Health (NIH) being conducted across the country

Where can I learn more about eating disorders?

Free brochures and shareable resources.

• Eating Disorders: About More Than Food : A brochure about the common eating disorders anorexia nervosa, bulimia nervosa, and binge-eating disorder, and various approaches to treatment. Also available en español .
• Let’s Talk About Eating Disorders : An infographic with facts that can help shape conversations around eating disorders. Also available in en español .
• Shareable Resources on Eating Disorders : Help support eating disorders awareness and education in your community. Use these digital resources, including graphics and messages, to spread the word about eating disorders.
• Mental Health Minute: Eating Disorders : Take a mental health minute to watch this video on eating disorders.
• Let’s Talk About Eating Disorders with NIMH Grantee Dr. Cynthia Bulik : Learn about the signs, symptoms, treatments, and the latest research on eating disorders.

Research and statistics

• NIMH Eating Disorders Research Program : This program supports research on the etiology, core features, longitudinal course, and assessment of eating disorders.
• Journal Articles   : References and abstracts from MEDLINE/PubMed (National Library of Medicine).
• Statistics: Eating Disorders

Last Reviewed: January 2024

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Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa

Annelies e. van eeden.

a Parnassia Psychiatric Institute, The Hague, The Netherlands

b University of Groningen, University Medical Center Groningen, Department of Psychiatry, Groningen, The Netherlands

Daphne van Hoeken

Hans w. hoek.

c Columbia University, Mailman School of Public Health, Department of Epidemiology, New York, New York, USA

Purpose of review

To review the recent literature on the epidemiology of anorexia nervosa and bulimia nervosa in terms of incidence, prevalence and mortality.

Recent findings

Although the overall incidence rate of anorexia nervosa is considerably stable over the past decades, the incidence among younger persons (aged <15 years) has increased. It is unclear whether this reflects earlier detection or earlier age of onset. Nevertheless, it has implications for future research into risk factors and for prevention programs. For bulimia nervosa, there has been a decline in overall incidence rate over time. The lifetime prevalence rates of anorexia nervosa might be up to 4% among females and 0.3% among males. Regarding bulimia nervosa, up to 3% of females and more than 1% of males suffer from this disorder during their lifetime. While epidemiological studies in the past mainly focused on young females from Western countries, anorexia nervosa and bulimia nervosa are reported worldwide among males and females from all ages. Both eating disorders may carry a five or more times increased mortality risk.

Anorexia nervosa and bulimia nervosa occur worldwide among females and males of all age groups and are associated with an increased mortality risk.

INTRODUCTION

This review aims to provide an overview of the recently published studies on the epidemiology of anorexia nervosa and bulimia nervosa. It is an update of previous reviews on this subject in this journal [ 1 – 3 ]. For a review of the epidemiology of binge eating disorder, see Keski-Rahkonen in this issue [ 4 ]. 

no caption available

Epidemiological studies provide information about the distribution (who, when and where) of disorders in a defined population and its trends over time. For eating disorders, there are some methodological problems regarding epidemiological research. Eating disorders are relatively rare in the community and help seeking is often avoided or delayed, for example for reasons of denial (particularly in anorexia nervosa) or stigma and shame (particularly in bulimia nervosa). These factors make general population studies on eating disorders costly and ineffective. Several strategies have been used to beat this problem, in particular the use of psychiatric case registers and other medical record-based studies. We must bear in mind that the results of these studies are an underestimation of the occurrence of eating disorders in the community, because not all patients will seek help, will be detected by their general practitioner or be referred to healthcare services. Moreover, different rates over time could be due to different case detection systems and diagnostic criteria, increased awareness leading to earlier detection and referral, and broader availability of treatment facilities, instead of a true increase in occurrence [ 1 , 5 ].

To review the literature, we searched for articles published in English using Medline/PubMed , Embase, PsycINFO and Google Scholar, using several key terms relating to epidemiology, anorexia nervosa and bulimia nervosa. We also checked the reference lists of the articles that we found for any additional articles missed by the database search.

Incidence is the number of new cases of a disorder in a population over a specified period of time (usually 1 year). The incidence rate of eating disorders is commonly expressed per 100 000 persons per year (100 000 person-years). The study of newly developed cases of an eating disorder provides clues to unravel its etiology [ 6 ]. It is noteworthy that healthcare register-based incidence rates represent the situation at the moment of detection, which is likely to be later than the moment of disorder onset.

Incidence of anorexia nervosa

Martinez-Gonzalez et al. [ 7 ▪ ] conducted a systematic review and meta-analysis of 31 published studies from 1980 to 2019 on the incidence of anorexia nervosa in females, mainly from Western countries. The incidence rates varied widely depending on the methodology, population and diagnostic criteria used. They reported on the incidence rates of only three population-based studies: 120 per 100 000 person-years among Swedish females aged 20–32 years [ 8 ], 200 per 100 000 person-years among Spanish females between the age of 12 and 22 years [ 9 ] and 270 per 100 000 person-years in Finnish twin females aged 15–19 years [ 10 ]. The pooled incidence rate of studies based on outpatient healthcare services (8.8 per 100 000 person-years; 95% confidence interval, CI: 7.8–9.8) was higher than that of hospital admissions (5.0; 95% CI 4.9–5.1) [ 7 ▪ ]. Compared to these all-age rates, the pooled incidence rates were higher for females aged 10–29 years, both in outpatient healthcare services [63.7 per 100 000 person-years (95% CI 61.2–66.1)] and in hospital admissions [8.1 (95% CI 7.6–8.5)] [ 7 ▪ ]. Furthermore, for healthcare register-based studies the incidence rates of anorexia nervosa showed a significant increase over time, especially in outpatient healthcare services. This does not necessarily mean a true increase in the occurrence of anorexia nervosa, as it could represent improved public awareness, detection and treatment rates over time.

Few studies have examined the incidence of anorexia nervosa in the general population; a limitation also encountered in the systematic review by Martinez-Gonzalez et al. [ 7 ▪ ]. The most recent study by Silen et al. [ 11 ▪ ] assessed the incidence rate of anorexia nervosa between the ages of 10 and 20 years according to the Diagnostic and Statistical Manual of Mental Disorders 5th Ed. (DSM-5) criteria in Finnish twins born between 1983 and 1987, yielding an incidence rate of anorexia nervosa of 320 (95% CI 230–440) per 100 000 person-years in the total group, 580 (95% CI 430–810) per 100 000 person-years among females and 30 (95% CI 10–310) per 100 000 person-years among males. These rates are higher than the rates in females described by Martinez-Gonzalez et al. [ 7 ▪ ]. This might be due to the use of the ‘broader’ DSM-5 criteria for anorexia nervosa by Silen et al. [ 11 ▪ ], and to the fact that twins may share genetic and environmental risk factors for anorexia nervosa, leading to a potential overestimation.

Population-based incidence rates are much higher than those derived from primary care and healthcare facilities, reflecting the selection filters on the pathways to (psychiatric) care [ 5 ]. Studies in general practices present incidence rates at the earliest stage of detection within the healthcare system. There have been no recent publications on all age groups in primary care since the previous review in this journal [ 1 ], that included a Dutch primary care study [ 12 ] which examined new cases with anorexia nervosa in a large representative sample of the Dutch population. The overall incidence rate of anorexia nervosa in Dutch females and males of all ages in primary care was fairly constant during three decades: in 1985–1989 it was 7.4 (95% CI 5.6–9.7) per 100 000 person-years, in 1995–1999 7.8 (95% CI 6.0–10.1) and in 2005–2009 6.0 (95% CI 4.3–8.1) [ 12 ]. Although no new studies have been published on incidence rates of anorexia nervosa in the total primary care population, Wood et al. [ 13 ▪ ] investigated 11- to 24-year-olds in England and found stable incidence rates between 2004 and 2014 (27.4 per 100 000 person-years; 95% CI 26.0–29.0). Demmler et al. [ 14 ] studied the incidence rate of eating disorders (all combined) in general practices in the UK since 2008, and reported a slight decline. The authors ascribe this finding to a decreasing trend in incidence of bulimia nervosa and a stable level of anorexia nervosa incidence, but they did not report rates per eating disorder diagnosis. Another primary care study among 10- to 19-year-olds in the UK reported an increased incidence rate in the age group of 13–16 years for all eating disorders combined, comparing 2018 rates to those in 2003 [ 15 ]. It is unclear whether this reflects a true increase in incidence or a shifting in age at detection.

The study of Reas and Ro [ 16 ▪ ], which was included in the meta-analysis by Martinez-Gonzalez et al. [ 7 ▪ ], described recent time trends in the incidence of anorexia nervosa in persons aged 10–49 years, using secondary care data of the Norwegian National Patient Register. The overall incidence rates for males and females combined were stable (differences nonsignificant) from 2010 to 2016, both for narrowly defined anorexia nervosa (18.8–20.4 per 100 000 person-years) and for broadly defined anorexia nervosa (33.2–39.5 per 100 000 person-years). They were also stable per sex for narrowly defined anorexia nervosa: in females 36.3–42.3 per 100 000 person-years, and in males 2.2–4.0 per 100 000 person-years; and for broadly defined anorexia nervosa: in females 63.3–79.1 per 100 000 person-years, and in males 4.4–5.9 per 100 000 person-years. The male to female ratio was found to be 1 : 13 for narrowly defined anorexia nervosa and 1 : 14 for broadly defined anorexia nervosa. This is in accordance with other studies showing considerably lower incidence rates for males, usually by more than a factor of 10, in comparison to females [ 11 ▪ , 12 ]. The incidence of anorexia nervosa according to DSM-5 criteria in 8- to 17-year-olds was examined in secondary care services in the UK and Ireland [ 17 ]. The overall incidence rate was 13.7 (95% CI 12.9–14.5) per 100 000 person-years; in females it was 25.7 (95% CI 24.1–27.3) and in males 2.3 (95% CI 1.8–2.8).

In females, the highest incidence rate of anorexia nervosa is around the age of 15 [ 11 ▪ , 12 , 17 ]. Several studies report a remarkable increase in the incidence of anorexia nervosa among girls aged 10–14 years [ 16 ▪ , 17 ]. Although most research has been performed in young females, some studies report incident anorexia nervosa cases in later life as well [ 12 , 16 ▪ ]. It is noteworthy that the peri-menopausal period has been suggested as another high-risk period in female life for the onset or recurrence of eating disorders [ 18 , 19 ]. In males, findings regarding the peak period of anorexia nervosa onset are less clear. While some studies have shown comparable [ 11 ▪ ] or a somewhat higher (age 16) peak age of onset [ 17 ], others found lower peak ages of 12–13 years [ 20 ] in comparison to females.

In summary, recent studies on time trends show fairly stable incidence rates for anorexia nervosa in the last decades [ 12 , 16 ▪ ], although some healthcare register-based studies suggest an increase in the incidence of anorexia nervosa [ 7 ▪ ], which might be explained by greater public awareness, better detection and the use of broader diagnostic criteria. Incidence rates in males are found to be lower, usually by more than a factor 10, in comparison to females [ 11 ▪ , 16 ▪ ]. The rates in males should be interpreted as an underestimation because of underdetection due to a double stigma: the stigma of having a psychiatric disorder, and an additional stigma of suffering from a ‘female-specific’ disorder [ 21 ]. Finally, the finding that the incidence of anorexia nervosa is increasing in younger girls (<15 years) has important implications for future research into risk factors [ 22 ], the development of prevention programs for younger subjects, and the planning of healthcare services.

Incidence of bulimia nervosa

Few studies have investigated the incidence of bulimia nervosa. In the population cohort study of Finnish twins born in the 1980 s, the incidence rate of DSM-5 bulimia nervosa between 10 and 20 years of age was 100 (95% CI 60–190) per 100 000 person-years overall, and 180 (95% CI 110–340) per 100 000 person-years in females [ 11 ▪ ]. These population-based DSM-5 rates of bulimia nervosa are higher than DSM-IV rates for females aged 10–19 years identified in Dutch primary care (range 20.5–22.0 per 100 000 person-years) [ 12 ], partly because of the use of broader DSM-5 criteria in the Finnish study [ 11 ▪ ], but moreover because of the fact that only a small proportion of community ‘cases’ present to (primary) care [ 3 , 5 ]. It is of note that the Finnish study [ 11 ▪ ] investigated the incidence rate between 10 and 20 years of age, which only partly covers the peak age period of 15 to 29 years suggested by other studies [ 12 , 16 ▪ ].

The Dutch primary care study showed a significant decrease in the all-age incidence rate of bulimia nervosa according to DSM-IV criteria over three decades: in 1985–1989 it was 8.6 (95% CI 6.7–11.0), in 1995–1999 6.1 (95% CI 4.5–8.2) and in 2005–2009 3.2 (95% CI 2.0–4.9) per 100 000 person-years [ 12 ]. The English primary care study in 11- to 24-year-olds also showed a significant decline in the incidence rate of bulimia nervosa between 2004 and 2014 (incidence rate ratio: 0.5; 95% CI 0.3–0.7) [ 13 ▪ ]. Also, Demmler et al. [ 14 ] explained their all-age finding of a slight decrease in the incidence rate of all eating disorders combined in primary care to a declining trend in incidence of bulimia nervosa.

Findings of the Norwegian National Patient Register study [ 16 ▪ ] support a significant decline in overall incidence rates of bulimia nervosa in secondary care between 2010 and 2016, both in narrowly defined bulimia nervosa [2010: 18.5 per 100 000 person-years (95% CI 16.9–20.2); 2016: 16.1 (95% CI 14.6–17.2)] and in broadly defined bulimia nervosa (2010: 29.4 per 100 000 person-years (95% CI 27.4–31.5); 2016: 26.9 (95% CI 24.9–28.8). A significant decrease in incidence rates was found in all age groups, except for a trend of an increase among girls aged 10–14 years, suggesting a shift to earlier ages of onset or detection. The peak incidence was among females aged 20–29 years. In males, the incidence rates were low and stable over time, ranging between 0.9 and 1.6 for narrowly defined bulimia nervosa, and ranging between 1.7 and 2.5 for broadly defined bulimia nervosa. The male to female ratio was found to be 1 : 24 for narrowly defined bulimia nervosa and 1 : 26 for broadly defined bulimia nervosa. Incident cases of bulimia nervosa also occur in later life [ 12 , 16 ▪ ].

In conclusion, there is a decline in incidence rates of bulimia nervosa over time. The peak age of incidence ranged between 15 and 29 years. Studies of incidence in males are scarce, but the rates are found to be much lower than in females.

Incidence of anorexia nervosa and bulimia nervosa in non-Western countries

Most epidemiological studies on eating disorders have been conducted in Western countries. Although studies assessing the epidemiology of eating disorders in non-Western countries are still scarce, we will highlight the most recent findings. Two Taiwanese studies [ 23 ▪ , 24 ] used national health insurance claim data to investigate the epidemiology of eating disorders between 2001 and 2013 in 10- to 49-year-old persons. In comparison to Western countries, the overall anorexia nervosa incidence rate in Taiwan is very low (1.1–1.3 per 100 000 person-years), but stable over time. Regarding bulimia nervosa, the incidence rates in Taiwan among females increased in the years up to 2009 [21.6 (95% CI 17.8–25.4) per 100 000 person-years] and then decreased [16.3 (95% CI 12.8–19.8) per 100 000 person-years] [ 24 ], following the trend in changes in incidence of Western countries, although a decade later. The incidence in Taiwan differs from that in Western countries in terms of older age at detection of anorexia nervosa and bulimia nervosa (20–29 years) and an increase in incidence among adults rather than adolescents [ 23 ▪ , 24 ]. This last finding aligns with findings of increasing numbers of persons in midlife with incident eating disorders in Western countries [ 19 ].

A study using data and methodology from the Global Burden of Disease (GBD) Study 2017 [ 25 ] reported increasing incidence rates of anorexia nervosa and bulimia nervosa from 1990 to 2017 in China, which is in contrast with the stable (anorexia nervosa) and decreasing (bulimia nervosa) rates in Western countries, but in line with the general trend of an increase in rates in all psychiatric diagnoses in China. Because of methodological issues related to the low prevalence and lack of global coverage of epidemiological studies for eating disorders, GBD calculations on these data must be interpreted with caution [ 26 , 27 ]. In this case [ 25 ], study results were difficult to check because 15 of the 39 publications from which data were included had been published in Chinese. From the abstracts of the included studies it would appear that in at least 26 of the 39 publications no formal eating disorder diagnosis had been applied, and that none of the studies addressed incidence. This casts doubts on the validity of the findings.

Prevalence is the proportion of cases in a population present at a certain point or interval in time. The point prevalence is the prevalence at a specific date (point) in time. The 12-month prevalence is the prevalence over an interval of a year. The lifetime prevalence is the proportion of the population that has had the disorder at any moment in life up to the moment of registration. In general, lifetime prevalence rates are higher than point and 12-month prevalence rates, especially when assessed in older populations. Prevalence indicates the demand for care and is therefore useful in the planning of healthcare facilities. Many studies have assessed the prevalence of anorexia nervosa and bulimia nervosa. In this review, we focus on recently published systematic reviews and meta-analyses, supplemented by recently published population-based studies that have not been included in the described reviews and meta-analyses.

Prevalence of anorexia nervosa

Galmiche et al. [ 28 ] have performed an extensive systematic review of 94 studies published between 2000 and 2018 that addressed the prevalence of formally diagnosed eating disorders in the general population. They explained the high variability of prevalence rates by the use of different diagnostic instruments [most commonly used: Structured Clinical Interview for DSM (13%), Composite International Diagnostic Interview (12%) and Eating Disorder Examination (11%)], diagnostic criteria [DSM-IV (78%), DSM-5 (14%) and DSM-III-R (4%)] and clinical investigation methods [face-to-face interview (51%), paper-and-pencil questionnaire (27%) or online or by telephone (22%)]. Weighted means were constructed from the prevalence rates and the population size of each study included, but were most likely not stratified for age. No confidence intervals were provided, only minimum-maximum ranges of the prevalence rates. The authors themselves conclude that the small number of studies makes it difficult to estimate weighted mean sex ratios. These limitations hamper the interpretation of some findings that are at odds with previous literature, in particular for point prevalence and 12-month prevalence rates. We therefore reproduce only the ranges of lifetime prevalence rates of anorexia nervosa, which were 0.1% to 3.6% in females and 0% to 0.3% in males.

Another systematic review and meta-analysis by Qian et al. [ 29 ] included 33 studies published between 1990 and 2020 on the prevalence of anorexia nervosa in the population. All studies combined, an overall lifetime prevalence rate of 0.2% (95% CI 0.06–0.3) was found. In studies applying DSM-5 criteria (18%; all in Western countries) a higher overall lifetime prevalence rate was found [0.9% (95% CI 0.7–1.1)]. This is in line with previous research showing an increase in anorexia nervosa prevalence rates when applying DSM-5 criteria, in comparison to rates according to DSM-IV criteria [ 30 , 31 ]. Lifetime prevalence rates in males and females (Table ​ (Table1) 1 ) were in the lower range of the rates described in the review of Galmiche et al. [ 28 ]. This could be explained by a large proportion of studies that had been conducted in Asia (40%) with very large sample sizes and much lower rates compared to Western countries, and the broader period studied (1984–2017) with especially lower prevalence rates before 2000 [ 29 ]. That is in contrast to findings described in a previous review in this journal [ 1 ] and to the notion that anorexia nervosa rates in Asian countries have been increasing in recent years and that they currently appear to be comparable to, or even higher than, those in Western countries [ 32 – 34 ]. In the review by Qian et al. [ 29 ], 6 of the 33 studies included had been published in Chinese and so the results were difficult to evaluate. However, there seems to be a lack of population-based studies using formal diagnostic interviews and applying DSM (-III-R, -IV, or -5) or International Classification of Diseases 10th Ed. (ICD-10) criteria. In Asia ‘non fat-phobic’ presentations of anorexia nervosa are common. In the DSM-5 the possibility of ‘persistent behaviour that interferes with weight gain’, which would apply to nonfat phobic presentations, is added to the DSM-IV B-criterium ‘intense fear of gaining weight or becoming fat’. Thus, the replacement of DSM-IV by DSM-5 criteria for anorexia nervosa will ultimately lead to higher rates among Asian people.

Overview of recently published studies on prevalence rates. Studies are grouped by design and listed in chronological order

CI, confidence interval; NR, not reported; SD, standard deviation; SE, standard error.

In their systematic review, Lindvall Dahlgren, Wisting and Ro [ 35 ] focused specifically on the prevalence of DSM-5 defined anorexia nervosa in the general population. Nineteen studies published until 2017 were included. Lifetime prevalence rates for anorexia nervosa in females differed according to the study method; 1.7–3.6% in studies with two-stage design and 0.8–1.9% in interview-based studies. Point prevalence rates in females ranged from 0.06% to 1.2%, predominantly assessed with self-reports.

Since this systematic review [ 35 ], several studies [ 11 ▪ , 36 ▪▪ , 37 , 38 ▪ , 39 – 43 ] have been published that investigated prevalence according to DSM-5 criteria. The prevalence rates reported in these recent studies are shown in Table ​ Table1 1 and are largely in line with those reported in the review. However, the population-based study of Finnish twins born in the 1980 s [ 11 ▪ ], in which the whole sample was diagnostically interviewed, found higher lifetime prevalence rates for anorexia nervosa: 6.2% (95% CI 4.6–8.3) in females and 0.3% (95% CI 0.08–1.3) in males. Suggested explanations for the higher rate found among females were the twin nature of the study, the thorough anorexia nervosa assessment and Finnish socio-cultural characteristics favouring a drive for thinness. Only 55% of the females identified with anorexia nervosa in the study reported that they had been diagnosed in real life by a healthcare professional.

Although epidemiological studies have mainly focused on the traditionally known high-risk group of young females, it has been shown in recent years that anorexia nervosa is prevalent among older persons as well [ 18 , 19 ]. The highest lifetime prevalence rates are found in adults, because of the accumulation of anorexia nervosa first emerging in the peak age period of adolescence [ 44 ] combined with incidence later in adulthood. A longitudinal, population-based study among Polish males showed that anorexia nervosa was prevalent in all age groups (10–80 + years) [ 45 ]. Although a decrease in point prevalence among females over a 30-year follow-up period was found, with no anorexia nervosa cases by age 50 [ 46 ▪ ], the 12-month prevalence rate in 40- to 50-year-old females was still 0.2% in another study [ 36 ▪▪ ].

Prevalence of bulimia nervosa

The three previously discussed systematic reviews and meta-analyses [ 28 , 29 , 35 ] also reported prevalence rates for bulimia nervosa. The lifetime prevalence rates for bulimia nervosa ranged from 0.3% to 4.6% in females and from 0.1% to 1.3% in males in the extensive systematic review by Galmiche et al. [ 28 ]. As discussed previously, we refrain from reproducing the 12-month and point prevalence rates they report for methodological reasons.

Qian et al. [ 29 ] reported an overall lifetime prevalence rate for bulimia nervosa of 0.6% (95% CI 0.3–1.0). This review included a relatively large (40%) proportion of Asian studies. For bulimia nervosa the lifetime prevalence in Western countries was 7.3 times higher than that in Asian countries. The lifetime prevalence rates in females and males (Table ​ (Table1) 1 ) were close to the rates described by Galmiche et al. [ 28 ]. The pooled overall lifetime prevalence rate rose up to 1.4% (95% CI 0.0–6.3), when using only studies that applied DSM-5 criteria (18%; all in Western countries) [ 29 ]. Other studies supported this increase [ 30 , 31 ], which could be explained by the lower required frequency of binge eating and compensatory behaviour in DSM-5 compared to DSM-IV.

Lindvall Dahlgren et al. included only studies that had applied DSM-5 criteria and found few studies on bulimia nervosa, but the authors reported preliminary evidence for an increase in bulimia nervosa prevalence [ 35 ]. Two two-stage studies reported a point prevalence rate of 0.6% in females [ 30 , 48 ]. The lifetime prevalence rate was found to be 2.6% among females in one interview-based study [ 49 ]. In self-report studies, point prevalence rates ranged from 0.5% to 8.7% in females.

Since these systematic reviews, several studies on the prevalence of DSM-5 defined bulimia nervosa [ 11 ▪ , 36 ▪▪ , 37 , 38 ▪ , 40 – 43 , 47 ▪▪ ] have been published in recent years. Among females, lifetime prevalence rates around 2.3% (range 2.1–2.6%) were consistently found [ 11 ▪ , 36 ▪▪ , 42 , 47 ▪▪ ], which gives further support for an increase in bulimia nervosa prevalence since the introduction of DSM-5 criteria. Only one study in a large population-based sample of US adults [ 38 ▪ ] reported a substantially lower lifetime prevalence rate [0.5% (Standard Error 0.06)] in females. Possible explanations for this low rate are the use of lay interviewers rather than clinicians and the use of a questionnaire that has not been validated for eating disorder diagnoses. The combination of these factors could lead to underreporting, especially in the case of bulimia nervosa where stigma and shame around bingeing and purging play an important role.

Few recent studies reported on prevalence in males. The results were in the same order as found in the systematic reviews [ 28 , 29 ], with lifetime prevalence rates ranging between 0.1% and 1.2% [ 11 ▪ , 38 ▪ , 47 ▪▪ ]. In males like in females [ 36 ▪▪ , 46 ▪ ], bulimia nervosa does occur in all age groups up to the age of 80, although the prevalence declines after age 30 [ 45 ].

The preliminary evidence for an increase in prevalence of bulimia nervosa in population-based studies is noteworthy in the face of decreasing incidence rates in primary and secondary care. One possible explanation is that people who have a lower frequency of binge eating and compensatory behaviour (meeting DSM-5 but not DSM-IV criteria, i.e. once a week) seek help less often than those who have this behaviour more often, and thus are less often included in care-based studies. Future research is needed to clarify this apparent discrepancy.

Mortality could be described as an incidence rate in which the event being measured is death. The crude mortality rate (CMR) is the number of deaths within the study population over a specified period. The standardized mortality ratio (SMR) is the ratio of observed deaths in the study population versus that of expected deaths in the population of origin. For comparison reasons the SMR is preferred, because the CMR is not standardized for age and sex. Mortality is often used as an indicator of the severity of a disorder.

In a previous review in this journal [ 27 ], it has been reported that both anorexia nervosa and bulimia nervosa were associated with significantly increased mortality rates. In comparison to age-matched and sex-matched people in the general population, the mortality risk was around two times higher in people followed up after outpatient treatment for anorexia nervosa, or after any treatment for bulimia nervosa. In people followed up after inpatient treatment for anorexia nervosa, the mortality risk was even over five times higher. Since this previous review, a few new studies have been published.

In a landmark meta-analysis of worldwide eating disorder mortality rates by Arcelus et al. [ 50 ] the CMR of anorexia nervosa patients was 5.1 deaths per 1000 person-years (95% CI 4.0–6.1). The SMR was 5.9 (95% CI 4.2–8.3), i.e. an almost 6 times increased risk. In a recent study, after 5 years follow-up the SMR of anorexia nervosa inpatients with (complications of) severe malnutrition was found to be as high as 15.9 (95% CI 11.6–21.4) [ 51 ]. This study population was probably more severely affected than most of the study populations included in the meta-analysis [ 50 ]. For bulimia nervosa, Arcelus et al. reported a CMR of 1.7 per 1000 person-years (95% CI 1.1–2.4) and a SMR of 1.9 (95% CI 1.4–2.6) [ 50 ]. Recently, in a large 12-year follow-up study a higher mortality risk was found in females after inpatient treatment for bulimia nervosa compared to similar-age females hospitalized for pregnancy-related events [adjusted hazard ratio 4.7 (95% CI 2.1–10.8)] [ 52 ]. This difference could be even larger when compared to the general population. Iwajomo et al. investigated mortality after hospitalization for an eating disorder (anorexia nervosa, bulimia nervosa or eating disorder not otherwise specified) in a Canadian population-based cohort [ 53 ▪ ]. Although results were not presented for each eating disorder separately, the total SMR was five times higher compared to the general population [SMR 5.1 (95% CI 4.8–5.3)]. Rates were higher for males [SMR 7.2 (95% CI 6.6–8.0)] compared to females [SMR 4.6 (95% CI 4.3–4.9)]. This is in line with other recent studies that also found higher mortality rates among males: in people treated for bulimia nervosa in secondary mental healthcare services an overall SMR of 2.5 (95% CI 1.5–4.0) was reported, with significantly higher rates among males compared to females [crude hazard ratio 5.4 (95% CI 1.8–16.5)] [ 54 ]. In another study on hospitalization for anorexia nervosa, in-hospital mortality in males was more than twice that for females [odds ratio 2.4 (95% CI 1.5–3.8)] [ 55 ]. However, in a study directly comparing males and females from the same hospital, from the same treatment period and for the same follow-up period, no significant differences in SMR were found for anorexia nervosa or for bulimia nervosa [ 56 ▪ ], which might be due to the relatively small sample size of males. The SMRs for each sex-group [ 57 , 58 ] have already been described in the previous review [ 27 ]. While there were no significant differences in mortality rates, males with anorexia nervosa or bulimia nervosa did die sooner in comparison to females with anorexia nervosa or bulimia nervosa [ 56 ▪ ].

In summary, recent findings accentuate high mortality rates for anorexia nervosa and bulimia nervosa, with highest rates among those who received inpatient treatment for anorexia nervosa. Although results are still inconclusive, the suggestion that males have a probably higher mortality risk than females underscores the clinical relevance of detecting and treating anorexia nervosa and bulimia nervosa in males.

Anorexia nervosa and bulimia nervosa occur among females and males of all age groups worldwide and are associated with an increased mortality risk. The trend of a decreasing peak age at incidence has implications for future research into risk factors, the development of earlier prevention programs and planning of treatment services. Besides the well-known risk group of young females from Western countries, the occurrence of anorexia nervosa and bulimia nervosa in males, older persons and non-Western countries highlights the need for further research in these groups. Moreover, improved awareness will lead to earlier detection and treatment in these groups that suffer from an extra stigma of a ‘young, Western, female-specific’ psychiatric disorder.

Acknowledgements

The authors would like to thank Judith Offringa for her editorial assistance.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

• ▪ of special interest
• ▪▪ of outstanding interest

• Eating Disorders

Hope and Hesitation in the Journey of Anorexia Recovery

Moving forward by embracing ambivalence in anorexia treatment..

Posted May 31, 2024 | Reviewed by Tyler Woods

• What Are Eating Disorders?
• Find a therapist to heal from an eating disorder
• When we uncover the "benefits" of anorexia, we take a step towards recovery.
• The anorexic wish delves into the desire to stay thin while yearning for physical and emotional health.
• Through an attuned treatment approach, using compassion and validation, we navigate ambivalence in therapy.
• Expanding self-evaluation means strengthening domains well beyond food and weight control.

Anorexia is like having a distorted mirror in your mind that makes you see yourself as bigger than you really are. It's this relentless fear of gaining weight that drives people to skip meals or eat very little, sometimes to the point of starvation. But it's not just about wanting to be thin; it's also this constant battle with yourself, feeling like you're never thin enough. Anorexia can be devastating, impacting your mental and physical health along with your relationships and career .

But My Anorexia Feels So Good

One of the biggest challenges in treating anorexia nervosa is that individuals often hold onto aspects of the disorder that they experience as positive or beneficial. These perceived "benefits" invariably create resistance to treatment and make it difficult for individuals to fully commit to recovery.

It may be surprising to some, but there are many aspects of anorexia that people find gratifying. There can be pride in the sense of control anorexia offers, both in terms of body control and more general feelings of control in one’s life. There can be a sense of achievement associated with weight loss in a culture that values thinness. Individuals with anorexia often get attention and validation from unsuspecting acquaintances for adhering to strict dietary habits. The food management of anorexia and the never-ending quest for thinness may serve as a distraction from underlying emotional pain and sometimes even a substitute for emotional connection. Often, people with anorexia form their identity around being thin or disciplined. All of these aspects, while providing temporary relief or validation, ultimately perpetuate the disorder and pose significant risks to physical and mental health.

The Anorexic Wish: To Feel Better but Stay Thin

A great example of ambivalence in anorexia recovery is what can be referred to as “the anorexic wish.” The anorexic wish is the desire to stay thin but restore both physical and emotional health. There's often a genuine desire to recover and reclaim one's health, happiness , and autonomy, but not at the expense of weight gain. Individuals may recognize the toll that anorexia has taken on their physical and mental well-being, as well as its impact on their relationships, goals , and overall quality of life. They may long for freedom from the relentless cycle of food and weight obsessions, the isolation of their illness, and the constant fear of physical deterioration or death. Still, however, there’s a profound fear of gaining weight or losing control over one's body, fueled by the pervasive societal emphasis on thinness and the internalized belief that being thin equates to worthiness, success, or acceptance. This desire to maintain a thin body may be intertwined with a sense of identity and self-esteem , making it challenging to let go of even when faced with the negative consequences of the eating disorder .

Addressing Ambivalence in Anorexia Treatment

Navigating this dual desire to stay thin while also wanting to get well requires a compassionate and individualized approach in treatment. Therapists work collaboratively with individuals to explore and validate their conflicting emotions and motivations, helping them untangle the complex web of thoughts and feelings that underlie their eating disorder. This may involve addressing core psychological challenges, such as low self-esteem, perfectionism , or trauma , that contribute to the fear of weight gain and the need for control. The therapeutic space remains a place where individuals feel heard and understood, free from judgment or pressure to change.

In overcoming ambivalence about recovery, therapists help individuals challenge distorted beliefs about body image and worth, fostering a more flexible and compassionate relationship with food, exercise, and their bodies. Through cognitive-behavioral techniques, such as cognitive restructuring and exposure therapy , individuals learn to challenge the irrational fears and beliefs driving their eating disorder while gradually reintroducing nourishing behaviors and self-care practices.

Expanding How You See—and Value—Yourself

An important additional feature of treatment is the expansion of what we call “domains for self-evaluation.” Enhancing domains for self-evaluation in eating disorder treatment refers to identifying and strengthening specific areas of an individual's life—outside of food and weight control—that contribute to their sense of self-worth, identity, and overall well-being. These domains are targeted to help individuals develop a more balanced and positive self-image , which is crucial for recovery from eating disorders like anorexia nervosa, bulimia nervosa, or binge-eating disorder.

The Delicate Balance

Ultimately, recovery from anorexia involves finding a balance between honoring one's desire for thinness and prioritizing one's overall health and well-being. It's a journey of self-discovery and self-compassion, guided by the understanding that true healing comes from nurturing the body, mind, and spirit in harmony.

Navigating ambivalence in anorexia treatment requires a delicate balance of compassion, patience, and understanding. It's essential to acknowledge the conflicting emotions individuals may experience as they confront the daunting journey of recovery. By fostering a supportive environment that respects autonomy and honors the struggle, we can help empower those affected by anorexia to gradually embrace the possibility of healing and embark on a path toward reclaiming their lives. Progress may not be linear, but every step forward, no matter how small, is a triumph worth celebrating on the road to recovery.

To find a therapist near you, visit the Psychology Today Therapy Directory .

Melissa Gerson, LCSW, is founder and Clinical Director of Columbus Park Center for Eating Disorders, an outpatient facility providing treatment to individuals of all ages and genders.

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Concordia alumna develops a new trauma-informed art therapy program for people with anorexia nervosa

People with anorexia nervosa often view the condition as a close friend that they are hesitant to cut out of their lives, shunning therapy that might undermine their identity. There is evidence that anorexia nervosa can be caused by physical or emotional trauma  in relationships, but most recovery programs prioritize family-based therapy and recovery programs generally have a success rate of only 50 per cent .

Jennifer Kar Wei Lee, recently completed her Master of Arts in Creative Arts Therapies (Art Therapy Option, MA 24) at Concordia. Seeing a gap in conventional treatments, Lee created a new art therapy program  that uses attachment-focused and trauma-informed approaches. The aim is to help adolescents with restrictive anorexia nervosa strengthen their sense of self and find freedom from the controlling influence of the disorder.

Lee’s program presents an opportunity for partial hospitalization programs — where patients are medically stable and on the path to recovery — to offer a structured and thoughtful series of trauma-informed group art therapy sessions over ten weeks. Art therapy interventions are informed by the Expressive Therapies Continuum to create experiences and use that are mindful of their resemblance to food and to living with anorexia nervosa.

“We don't think about the development of anorexia nervosa from an attachment and trauma-informed lens enough,” explains Lee’s supervisor, Bonnie Harnden . “But it can be central to the development of an eating disorder. Jennifer’s thoughtful and thorough research brings a new and unprecedentedly wide look at how we can incorporate this into supporting those with eating disorders, helping those diagnosed and providing treatment to understand that having an eating disorder is a very particular kind of struggle.”

‘We need to tell the story in all kinds of different ways’

One thing that people with anorexia nervosa struggle with a lot is rigidity, Lee explains. “For a participant who needs more control in art making, very fluid paint might provoke a lot of anxiety at first, versus using pencils or pencil crayons. This gradually opens the doors to more anxiety-provoking materials, such as mushy clay that might remind people of certain foods, which allows for more expression and less rigidity.”

Art therapists running these sessions are responsible for creating a safe and predictable environment where participants are seen as people, not patients, and encouraged to express themselves as individuals that are not their eating disorder.

“We're understanding more and more that yes, talk therapy is very important, but we also need to tell the story in all kinds of different ways,” Harnden adds. “We need to tell the nervous system story. We need to tell the body story. Art, drama, music and play tell stories in incredible ways, but the expression itself also holds a kind of healing — a metaphor, meaning and depth that words can fail to capture. If we're only relying on talk therapy, we're really limiting the capacity to help people heal.”

Lee’s intervention plan is inspired by her own experience being hospitalized for an eating disorder as a teenager and being introduced to art therapy as part  of her treatment. “I was able to witness firsthand just how powerful art therapy could be, how healing it was for me personally and how much it brings people together in a community.”

She describes art therapy as tapping into another language that people can use to express themselves.

“When you are in talk therapy for an eating disorder, it’s almost like the therapist is the villain because you want to keep that eating disorder self intact, and talking to a therapist threatens that. With art making, it's much harder to filter your emotions and it’s more natural to be fully expressive. As art therapists, we do not interpret what our clients make; they have autonomy and control over their creations.”

Since completing her degree, Lee has moved to Ottawa, where she is practicing as a professional art therapist and Registered Psychotherapist (Qualifying) and continues her work on attachment, trauma and eating disorders. She hopes to work in a hospital or clinical setting and is passionate about engaging with children and youth.

To learn about art therapy or participate in a session, discover the Concordia Centre for the Arts in Human Development and the Concordia Arts in Health Centre .

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New integrated treatment could transform the lives of adults with life-threatening anorexia nervosa

Dr Agnes Ayton, study lead and chair of the Eating Disorders Faculty at the Royal College of Psychiatrists, said: “People who have anorexia nervosa are admitted to hospital, often involuntarily, when their condition becomes life threatening. They are often discharged when still malnourished and readmission rates are as high as 50 to 60%. 

“We adapted an integrated approach, building on work from Italy and Oxford over the last 20 years. We found providing uninterrupted stepped care to adults who agreed to the treatment transformed their outcomes. The positive results were beyond our expectations. This treatment model offers hope to those who have suffered with anorexia nervosa for many years.   “This important replication of previous work in Italy in real life NHS settings shows that the treatment model is robust and could potentially transform the lives of people with severe anorexia nervosa.” 

Former patient Lorna Collins, aged 40, says the treatment saved her life.

“I developed an eating disorder following a traumatic brain injury. I was admitted to hospital multiple times. Each time, I was discharged underweight and without proper follow-up care.   “After relocating to Buckinghamshire, I was referred to the Oxford team. The treatment I received was unlike anything I had experienced before. It saved my life. An eating disorder is no longer part of my identity. I am in full recovery. I am living proof that this approach can work.”  

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