Labeling and Defining Difficult-to-treat Anorexia Nervosa: A Systematic

Review and Critical Analysis

Catherine Broomfield1, Kristin Stedal2, Stephen Touyz1 and Paul Rhodes1
1School of Psychology, University of Sydney, 2Regional Department for Eating Disorders, Oslo University Hospital, Ullevål

Introduction Method continued Results continued

With Anorexia Nervosa (AN) having various presentations, attention Data extraction
Defining continued
has been directed towards particularly durable forms of the condition Information collected included:
in both research and clinical contexts [1-2]. A major hindrance in terms 1. The term used to explicitly label the subgroup;
8
of advancing the field, however, is the inconsistent labeling and 2. Additional term(s) used throughout the record; and
defining of this subgroup. 3. The explicit definition/criteria used to describe the subgroup. 7

6
This has two implications: Quality assessment
• Inconsistent recruitment of participants when researching this
5
A total of 32 records met the inclusion criteria with all the randomized

Frequency
sample of AN; and control trial studies representing high methodological quality after 4

• Misdiagnosing of patients who may or may not have a durable being assessed by a modified version of the Downs and Black [8] 3
course of the disease. Quality Index by Ferro & Speechley [9].
2

Despite research revealing recovery from AN is possible in the long- Results 1

term [3], approximately 20% of cases progress into a severe and 0

enduring AN (SE-AN; [4]) form, where recovery is often challenging. Labeling 5 5-7 7 10
Time Frame (Years)
As a result, research efforts of recent times have been dedicated to
Figure 4. Frequency of duration period when a specific time frame
finding alternative treatment options that may better suit these 40 was used as the only defining feature for this subgroup of AN.
persistent presentations.
Of concern in this research is the repercussions of labeling these
35
Conclusion
30

patients, which may stigmatise this group further [5]. With this It was found that the terms chronic and severe and enduring were the

Occurrences
25
presentation of AN already isolating patients and their families from most commonly used adjectives when referring to SE-AN. In regards
the community as a result of the currently unsuccessful treatments 20
to criteria, illness duration and number of previously failed treatment
available to them, it is crucial that any label or definition provided to 15
attempts were the most common defining features within the literature.
this group be of benefit to improving patient-professional relationships 10
A 7-year period of enduring AN is what is most commonly referred to
[6]. 5
as the minimum time frame for classifying this form of the disease.
0

Chronic Severe and Long-standing Severe Enduring

Aim enduring With a 7-year duration period being the most popular in the literature,
Adjective
The aim of this review was to: the classifying of SE-AN needs to be debated given the implications of
Figure 2. Top five most common adjectives used in labels
1) Provide an overview in order to stimulate debate towards throughout the literature for this subgroup of AN. labeling and defining this condition in potentially young adults who
establishing a consensus into the labeling and defining of SE-AN; have been ill with AN since their early teenage years. At the current
and time, however, the referring to and defining of SE-AN is inconsistent
2) Ensure that any label and definition is not only of benefit to the Defining and further research is needed to determine a universal label and
medical practice but also the patients experiencing SE-AN. 30
criteria for defining this form of AN.
Method 25
References
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Search strategy 20
Occurences

Psychiatry, 14(1). doi: 10.1186/1471-244X-14-69

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guidelines [7], a comprehensive 10
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Paper was accepted for publication by the International Journal of Eating Disorders: Broomfield C, Stedal K, Touyz S, Rhodes P. Labeling and defining severe and enduring
anorexia nervosa: A systematic review and critical analysis. Int J Eat Disord. 2017;00:000–000. https://doi.org/10.1002/eat.22715
Contact: catebroomfield@hotmail.com