Studies have consistently found that up to 20% of people with anorexia nervosa experience a persistent illness, resulting in considerable psychosocial impairment, morbidity and mortality. This has been variously termed severe and enduring anorexia nervosa or longstanding anorexia nervosa (L-AN). Conflicting findings have hindered progress in distinguishing the nosological features of individuals with persistent illness.

This study aims to investigate the putative defining features of individuals reporting symptoms of L-AN, including consideration of their treatment trajectory.

This cross-sectional study, drawing from a mixed-methods design, utilised a sample of symptomatic individuals who reported experiencing eating disorder treatment (n = 208). Several qualitative and quantitative data strands (a–c) were embedded within a single, self-report questionnaire measuring eating disorder severity and treatment experiences. Between-group comparisons were used to compare those of shorter (<3 years) and longer (>7 years) duration of illness.

No between-group differences were found in measures of severity, including body mass index (kg/m2), eating disorder symptom scores, psychological distress or perceived health-related quality of life. However, those with L-AN had a significantly higher number of mental and physical health comorbidities, longer treatment delay, greater number of episodes of treatment and poorer subjective ratings of their treatment experiences.

Delineating L-AN by severity may be inappropriate; anorexia nervosa of any duration is a severe illness. This study suggests that treatments, or lack thereof, may have an inadvertent impact on duration of illness. Future focus needs to be on reconceptualising L-AN and its treatments. Treatment refinements informed by lived experience are proposed.

Anorexia nervosa is associated with high personal and financial costs for sufferers, carers and society in general, but little is known about the long-term health economic burden.

To examine healthcare utilisation, social assistance, sick leave and disability pension in individuals with anorexia nervosa over a period of 30 years.

Fifty-one individuals with adolescent-onset anorexia nervosa and 51 matched comparison cases (COMP) were recruited in the community and followed prospectively from 1985. All individuals were examined on five occasions. At the 30-year follow-up, mean age 44, data on in- and out-patient care, prescribed medications, social assistance, sick leave and disability pension were collected from Swedish national registers.

The anorexia nervosa group had more days of in-patient care (p < 0.001) and out-patient visits to psychiatry (p < 0.001), more days of sick leave (p = 0.006), more days of disability pension (p = 0.002) and were prescribed more psychotropic medication (p = 0.045) compared with the COMP group. Of the anorexia nervosa group, 22% had ever received a disability pension compared with 2% in the COMP group (p = 0.004) and less than half the anorexia nervosa group worked full-time at the 30-year follow-up. In the anorexia nervosa group, 45% had received social assistance at some point, compared with 22% in the COMP group (p = 0.02). Age at onset of anorexia nervosa emerged as a predictor of healthcare utilisation with significant odds ratios for psychiatric in-patient (odds ratio 0.61, 95% CI: 0.39, 0.94; p = 0.027) and out-patient care (odds ratio 0.63, 95% CI: 0.40, 0.98; p = 0.042), i.e. individuals with a later onset of anorexia nervosa were less likely to require psychiatric care.

The long-term burden of adolescent-onset anorexia nervosa comprises increased utilisation of healthcare and dependence on society for a significant minority. A later onset of anorexia nervosa predicted a lower healthcare utilisation.

Eating disorders, particularly anorexia nervosa and bulimia nervosa, are significant global health challenges.

This study analyses historical trends and forecasts future patterns of eating disorders among young adults aged 15–29 years using machine learning techniques.

Global data on anorexia nervosa and bulimia nervosa from the Global Burden of Disease study 2021 spanning 1990 to 2021 were analysed, examining incidence, prevalence and disability-adjusted life years (DALYs) across age groups, sociodemographic index (SDI) levels and regions. Eight machine-learning models were employed to forecast trends from 2022 to 2050.

Bulimia nervosa showed more pronounced increases compared to anorexia nervosa across all metrics. The 15–19 age group had the highest incidence rates, while the 20–24 age group showed the highest prevalence and DALY rates. Low SDI regions experienced substantial increases, with bulimia nervosa prevalence rising by 179.05%. East Asia demonstrated the most significant rise in age-standardised rates. The Prophet model best forecast anorexia nervosa trends, while ARIMA performed best for bulimia nervosa. Projections indicate continued increases through 2050 for both disorders.

The global burden of eating disorders among young adults is projected to increase significantly by 2050, with bulimia nervosa showing more rapid growth than anorexia nervosa. Substantial variations exist across age groups, SDI levels and regions. These findings highlight the urgent need for enhanced prevention programmes targeting high-risk age groups, strengthened healthcare capacity in rapidly developing regions and evidence-based policy interventions to address the growing global burden of eating disorders.

Shared genetic risk has been shown across psychiatric disorders. In particular, anorexia nervosa (AN), obsessive-compulsive disorder (OCD), and schizophrenia (SCZ) show shared genetic risk that matches clinical evidence of shared illness and cognitive phenotypes. Given this evidence, we leveraged a large US-based population-based study to determine genetic associations of disorder-specific and shared psychiatric, cognitive, and brain markers and explore whether the latter might be state versus trait markers in eating disorders.

We used data from the population-based Philadelphia Neurodevelopmental Cohort (N = 4,729) and conducted sex-stratified analyses to test for associations between genetic risk for three disorders (AN, OCD, and SCZ) and mental health phenotypes, neurocognitive traits, and cortical features in a non-clinical population. Exploratory analyses on cortical features were run on a subset with neuroimaging data (N = 626).

Genetic risk for AN was significantly associated with body image distortion (pFDR = 0.02), and body image distortion was significantly related to a reduction in grey matter volume (pFDR = 0.05).

Genetic risk for AN associates with AN trait in a non-clinical sample of youth, particularly in females. Whilst genetic risk was not associated with cognitive or cortical markers, the AN phenotype was associated with cortical markers.

Eating disorders are severe psychiatric conditions associated with high mortality rates, particularly among young people. These disorders often co-occur with self-harm and suicidal ideation, yet the temporal dynamics between these variables remain poorly understood.

This study aims to elucidate the longitudinal associations between symptoms of body dissatisfaction and disordered eating, self-harm and suicidal ideation using structural equation modelling.

Repeated measures of these phenotypes were used to construct a hypothetical model that includes cross-path analyses within and between the variables in two cohorts: the Twins Early Development Study (TEDS; ages 16, 21 and 26 years; N = 5196), representing a general population sample, and the COVID-19 Psychiatry and Neurological Genetics study (COPING; data collected between June 2020 and July 2021; N = 490), which focused on individuals with a history of anxiety or depression. In the TEDS cohort, symptoms of disordered eating, self-harm and suicidal ideation showed limited continuity across adolescence and young adulthood, with peak symptom severity at age 21 years.

Cross-domain associations revealed that both self-harm and suicidal ideation at age 21 years were more strongly associated with disordered eating at 26 years than the reverse. In contrast, the COPING cohort exhibited greater stability in symptoms over time but showed minimal cross-domain effects.

The effects of self-harm and suicidal ideation on disordered eating in early adulthood are stronger than the influence of disordered eating on suicidality.

Anorexia nervosa has potential to influence the development and function of the gastrointestinal system. We assessed the association between maternal anorexia nervosa and risk of gastrointestinal morbidity in offspring.

We analyzed a longitudinal cohort of 1,269,370 children born in Quebec, Canada, between 2006 and 2022. The exposure was maternal anorexia nervosa. The outcome was hospitalization for pediatric gastrointestinal disorders, including hypertrophic pyloric stenosis, inflammatory bowel disease, and other digestive morbidity. Follow-up ranged from 1 to 17 years. We used adjusted Cox regression models to obtain hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between maternal anorexia nervosa and pediatric gastrointestinal disorders.

A total of 2,447 children (0.2%) had a mother with anorexia nervosa. By age 17 years, the cumulative incidence of gastrointestinal disorders was higher among children whose mothers had anorexia nervosa than other children (165.7 vs. 129.4 per 1,000). Compared with no anorexia, maternal anorexia nervosa was associated with a greater risk of any childhood gastrointestinal disorder (HR: 1.42, 95% CI: 1.26–1.61), particularly hypertrophic pyloric stenosis (HR: 2.51, 95% CI: 1.35–4.66), inflammatory bowel disease (HR: 2.46, 95% CI: 1.67–3.64), and rectal hemorrhage (HR: 3.46, 95% CI: 1.97–6.09). Children whose mothers developed anorexia nervosa after age 20 years or were hospitalized more than once for anorexia had the greatest risk of gastrointestinal morbidity. The associations were not explained by digestive birth defects.

Maternal anorexia nervosa is associated with pediatric gastrointestinal disorders that could potentially be mitigated with psychosocial support, nutritional rehabilitation, and breastfeeding.

Pharmacological efforts to treat anorexia nervosa (AN) have predominantly repurposed medications that treat conditions with overlapping symptoms and yielded generally disappointing results. Despite limited empirical support, SSRIs are often prescribed to patients with AN. Whether SSRIs are effective in a subgroup of individuals with AN, such as those with depression, is not known.

A secondary analysis of a randomized trial of fluoxetine versus placebo for relapse prevention in AN was conducted. Participants (n = 92) were weight-restored women with AN who completed the Beck Depression Inventory (BDI) at the time of randomization. BDI scores were dichotomized to reflect moderate/severe depression (BDI > 20, n = 26). A Cox Proportional Hazards model estimated the association of the level of depression, medication, and their interaction with time to relapse. Mixed effects models examined the effects of medication on symptom trajectories in high versus low depression groups and whether depression severity modified the effect of the drug on symptom trajectory.

There was a significant interaction between medication and depression severity in time to relapse (hazard ratio = 0.46, 95% CI: [0.25, 0.85], p = .01). Depression severity modified the effect of fluoxetine on the time course of symptoms of depression (β = −0.27, 95% CI: [−0.42,-0.12], p = 0.001) and bulimia (β = −0.15, 95% CI: [−0.25,-0.05], p = 0.004) in the twelve month follow-up period.

Fluoxetine was more effective than placebo in reducing relapse among more depressed, weight-restored individuals with AN. These results require replication but provide support for the use of antidepressant medication for patients with AN who remain depressed following weight restoration.

Social function is increasingly demonstrated as a factor in risk, maintenance and outcome of eating disorders, but not emphasised in theoretical models of, and treatment approaches to, adolescent eating disorders.

To adapt Schmidt and Treasure’s cognitive interpersonal model of anorexia nervosa to incorporate developmental and transdiagnostic components.

Qualitative interviews with young people aged 12–16 years (inclusive), who are in contact with child and adolescent community eating disorders services, and their parents, subjected to thematic analysis.

Five key themes emerged that were mutually dependent on a sixth theme of emotion regulation and coping. These themes were: peer relationships, change and uncertainty, thinking styles, appearance and achievement-based values, and family relationships.

Peer relationships emerged as distinct from family relationships in this population, and a unifying theme was emotion regulation and coping. The framework could guide clinical assessment and the development or adaptation of interventions to address the themes identified. Research is needed to understand the role of the themes in treatment response and outcomes.

Anorexia nervosa (AN) is often regarded as ‘difficult to treat’. This may in part be due to co-occurring diagnoses and traits that are less directly targeted either at the point of formulation or in treatment. Schema therapy may be suitable for individuals with AN who have not benefited from first-line interventions. It offers a schema formulation and change techniques that target broader characterological ways of being. However, schema therapy is typically 18 months duration or longer, and therefore not well-suited to services with resource constraints. We present a schema-informed cognitive behavioural therapy (CBT) approach for AN, based on a formulation that encapsulates the experience of chronic unmet emotional need and which uses cognitive and behavioural techniques to target schema and schema mode change over a relatively brief treatment. We argue that the experiential techniques of schema therapy can augment the change process for those with AN, by gradually turning up the ‘emotional heat’ and increasing tolerance for emotion. After outlining this proposed model, we present findings from a case series of n=11 patients with AN or atypical AN. All patients had received first-line eating disorder treatment(s) previously and n=8/11 had prior experience of day or in-patient treatment. Results supported the acceptability and feasibility of schema-informed CBT for AN: no patients discontinued treatment early, mean number of sessions was 31 (SD 10.28), and patient satisfaction was high. Improvements were seen in AN psychopathology, depression/anxiety, schemas and schema modes, mostly with medium effect sizes. We propose areas for future research and consideration.

1. (1) To understand the rationale for a schema-informed CBT approach for anorexia nervosa.

2. (2) To understand the key components of schema-informed CBT for anorexia nervosa, including treatment objectives, stages of treatment and core methods.

3. (3) To evaluate the empirical evidence for schema-informed CBT with anorexia nervosa.

4. (4) To critically reflect on future opportunities for research and clinical practice with schema-informed CBT and eating disorders.

Considering the high likelihood of chronicity, it is imperative to understand the risk factors and outcomes associated with severe anorexia nervosa (AN), for which Danish registers provide a unique opportunity. We developed a measure of AN severity adapted from clinical literature for use in register-based research.

The study population included all Danish individuals born between 1963 and 2007 who were diagnosed with AN from 1969 to 2013. Using register data, we constructed the anorexia nervosa register-based severity index (AN-RSI), incorporating early or late illness onset, number of inpatient admissions and outpatient treatments, cumulative treatment length, and illness duration, each weighted based on clinical importance. Associations between AN-RSI scores, evaluated 5 years after first AN diagnosis, and mortality were estimated using survival analysis.

Among 9167 individuals diagnosed with AN, 132 died during follow-up: 17 from AN, 30 from suicide, and 85 from other causes. Higher AN-RSI scores were associated with increased rates of mortality from AN, somatic anorexia diagnosis, suicide, alcohol-related causes, and any cause. AN cases who scored in the top 20% of AN-RSI had especially high mortality rates. Furthermore, severe AN cases were also more likely to be in treatment in the next 5 years after severity was established.

AN-RSI effectively captures mortality and long-term treatment in the absence of detailed patient records and is associated with later mortality in AN patients. AN-RSI could serve as a tool to examine epidemiological and genetic risk factors associated with AN course and outcomes.

Involuntary treatment for patients with anorexia nervosa is common and lifesaving, but also highly intrusive. Understanding how morbidity patterns relate to involuntary treatment can help minimise its use.

We estimate the relative risk of involuntary treatment according to morbidity profiles in patients with anorexia nervosa.

This register-based cohort study included all individuals diagnosed with anorexia nervosa (ICD-10: F50.0, F50.1) between 1 January 2000 and 31 December 2016 in Denmark. Individuals were grouped by prior morbidities using latent class analysis (LCA). Cox proportional hazards regression estimated the relative risk of first involuntary treatment (e.g. involuntary admission, detention, locked wards) after a diagnosis with anorexia nervosa, regardless of the associated diagnosis. The relative risk of involuntary treatment was estimated with latent classes and the number of morbidities as exposure.

A total of 9892 individuals with anorexia nervosa were included (93.3% female), of which 821 (8.3%) individuals experienced at least one involuntary treatment event. The LCA produced six classes, with distinct morbidity profiles. The highest hazard ratio was observed for a group characterised by personality disorders, self-harm and substance misuse (hazard ratio 4.46, 95% CI: 3.43–5.79) followed by a high burden group with somatic and psychiatric disorders (hazard ratio 3.96, 95% CI: 2.81–5.59) and a group with developmental and behavioural disorders (hazard ratio 3.61, 95% CI: 2.54–5.11). The relative risk of involuntary treatment increased primarily with the number of psychiatric morbidities.

Specific morbidity groups are associated with highly elevated risk of involuntary treatment among patients with anorexia nervosa. Targeting preventive interventions to high-risk groups may help reduce the need for involuntary treatment.