A mixed-methods study in BJPsych Open has shown that commonly used indicators of anorexia nervosa severity did not differ by illness duration in a symptomatic, treatment-experienced community sample. Comparing patients with shorter duration (three years or less) and longer duration (seven years or more), the researchers found no significant between-group differences in body mass index, eating disorder symptom scores, depression, anxiety, or health-related quality of life.
In contrast, longer illness duration was associated with greater treatment burden and more negative treatment experiences. Patients in the longer-duration group reported a higher number of mental and physical comorbidities, longer delay before first treatment, more episodes of care, and poorer subjective ratings of treatment experiences, particularly those described as least helpful.
"Treatments, or lack thereof, may have an inadvertent impact on duration of illness," wrote lead study author Laura Kiely, of the School of Medicine at Western Sydney University, and colleagues, highlighting the possibility that care pathways can shape illness trajectory in ways that are not always therapeutic.
Qualitative findings emphasized that patients evaluated treatment less by modality and more by the therapeutic context in which it was delivered. Reports of helpful care focused on being understood, having autonomy and choice, and working within a collaborative therapeutic relationship that supported hope and engagement. Patients described clinicians who could sustain hope when motivation was low, framing this relational support as central to lasting change.
Least helpful care was commonly characterized by coercion, shaming interactions, and narrowly weight- or compliance-focused approaches. Some patients described these experiences as dehumanizing and depersonalizing, with more severe accounts describing them as traumatic. Across accounts, negative experiences were associated with reduced trust, diminished agency, and lower perceived helpfulness of subsequent care.
Identity disturbance and shame were recurrent themes. Patients described periods of disconnection from self and shame as drivers of illness maintenance, while recovery was described as a gradual process of rebuilding self-worth and identity. Quantitatively, identity disturbance was associated with symptom severity but not with illness duration, suggesting these targets warrant attention across stages of anorexia nervosa rather than being specific to longstanding presentations.
This study shifts attention from illness duration as a shorthand for severity to the treatment pathway and the experience of care. Patients' accounts suggest that autonomy, attunement, and a therapeutic relationship that sustains hope are central to what is experienced as helpful, while coercive or shaming care may be experienced as harmful.
"Delineating L-AN by severity may be inappropriate; anorexia nervosa of any duration is a severe illness," the researchers noted.
Disclosures can be found in the study.
Source: BJPsych Open
