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Eating disorders in adolescence: attachment issues from a developmental perspective

Manuela gander, kathrin sevecke, anna buchheim.

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Edited by: Gian M. Manzoni, eCampus University, Italy

Reviewed by: Julian B. Nesci, Austin Health, Australia; Alessandra Simonelli, University of Padova, Italy; Rossella Procaccia, eCampus University, Italy

*Correspondence: Manuela Gander, Institute of Psychology, University of Innsbruck, Innrain 52, Innsbruck, 6020, Austria, [email protected]

This article was submitted to Psychology for Clinical Settings, a section of the journal Frontiers in Psychology.

Received 2015 Mar 25; Accepted 2015 Jul 21; Collection date 2015.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

In the present article we review findings from an emerging body of research on attachment issues in adolescents with eating disorders from a developmental perspective. Articles for inclusion in this review were identified from PsychINFO (1966–2013), Sciencedirect (1970–2013), Psychindex (1980–2013), and Pubmed (1980–2013). First, we will outline the crucial developmental changes in the attachment system and discuss how they might be related to the early onset of the disease. Then we will report on the major results from attachment studies using self-report and narrative instruments in that age group. Studies with a developmental approach on attachment will be analyzed in more detail. The high incidence of the unresolved attachment pattern in eating disorder samples is striking, especially for patients with anorexia nervosa. Interestingly, this predominance of the unresolved category was also found in their mothers. To date, these transgenerational aspects are still poorly understood and therefore represent an exciting research frontier. Future studies that include larger adolescent samples and provide a more detailed description including symptom severity and comorbidity would contribute to a better understanding of this complex and painful condition.

Keywords: attachment, eating disorders, adolescence, measurement of attachment, unresolved attachment

Attachment Patterns in Eating Disorders

While eating disorders (ED) can affect individuals from different age groups, the average age of onset takes place during adolescence. During the second half of the 20th century, the prevalence rates of ED have dramatically increased and have remained relatively stable over the last 20 years ( Voderholzer et al., 2012 ). Results from different studies looking at the prevalence of ED indicate that between 1 and 4% of adolescents meet the DSM-IV-TR criteria for anorexia nervosa (AN) or bulimia nervosa (BN) and at least 5% meet the criteria for eating disorders not otherwise specified (EDNOS; Hoek, 2006 ; Allen et al., 2013 ). Adolescents seem to be the most at-risk group to develop an eating disorder and this is due to a number of different environmental, social, psychological and biological factors. Attachment theory, originating from work Bowlby’s (1969) , offers a comprehensive framework for understanding the individual and family characteristics contributing to the development of ED in this age group. Furthermore, it provides an insight into a range of different psychological functions like emotion regulation and interpersonal functioning which are relevant for ED.

Attachment has an important influence on how young people can deal with the challenging transformations during adolescence ( Allen, 2008 ). Throughout the developmental history of an individual, secure attachment relationships provide emotional support, comfort and availability especially during stressful situations and moments of important change. When children grow older, they start to internalize daily interactions and experiences with their parents. In other words, they develop so called “internal working models of attachment” that derive from variations in how caregivers respond to their child’s attachment behavior ( Bowlby, 1969 ). In securely attached infants, attachment events have led them to anticipate their caregivers’ availability, understanding and responsiveness. Consequently, they will experience themselves as competent and valuable. In contrast, when caregivers show a rejecting or inconsistent response to the signals of their children, they tend to experience themselves as incompetent and unlovable ( George and West, 2012 ). According to attachment theory, a secure quality of attachment relationship is crucial in solving developmental tasks in adolescence like adjusting to physical changes, creating an own identity or defining goals for the future and thus represents an important buffer for psychological risks.

During adolescence the redefinition of the parent–child relationship in accordance with the developmental process of individuation represents one of the most challenging tasks ( Allen, 2008 ; Dubois-Comtois et al., 2013 ). Teenagers achieve independence from their primary attachment figures on different emotional and behavioral levels. For example, they start to create alternative methods to deal with stress which range from relying on peers to using internal cognitive strategies. Furthermore, they make decisions independently, take actions on their own and have their personal attitudes and beliefs regarding spirituality, politics and moral values ( Allen and Miga, 2010 ). This struggle for autonomy can be very distracting as it seems to be directly in competition with their attachment system. On the one hand they need to master new environments on their own and thus decrease their need for dependence on their parents. On the other hand they seek their parents’ comfort and solace especially under conditions of severe stress. This often paradoxical situation can lead to tremendous stress. A successful negotiation between these contradictory issues can only be achieved when both parents and their children can openly communicate their current emotional states and related thoughts ( Cassidy, 2001 ; Allen, 2008 ).

Another important attachment issue of adolescence is the capacity to re-evaluate the nature of the attachment relationship with parents. When young people start to become more autonomous, they develop accurate and thoughtful responses to attachment experiences. Even if this process might be uncomfortable for parents, it is fundamental to form secure relationships with others in the future and reconsider and alter the own states of mind regarding attachment ( Allen, 2008 ). Theorists propose that difficulties of adolescents and their parents in facilitating developmental strivings toward independence are a significant precursor for the development of an ED ( Bornstein and Greenberg, 1991 ; Rhodes and Kroger, 1992 ).

The aim of this article is to review studies looking at attachment issues and their relation to adolescent ED from a developmental perspective. Additionally we will outline clinical implications of attachment-related issues in this age group which affect practice areas like psychological assessment, case formulation, therapy compliance and specialized intervention plans. A growing number of papers on attachment and ED have been published in the last decade, including some reviews ( O’Shaughnessy and Dallos, 2009 ; Zachrisson and Skårderud, 2010 ; Tasca et al., 2011 ; Tasca and Balfour, 2014 ). However, research examining attachment issues in adolescents with ED have only recently begun. To date, there is no review analyzing results in adolescents with ED in particular. In the present article, we want to expand previously published reviews by reporting on findings in the field of adolescent ED with a special focus on research adopting a developmental approach. In the upcoming sections, we will offer a comprehensive overview on the latest findings from self-report and narrative-based research in adolescents with ED. For the first time, we analyze results from studies with a developmental approach on attachment in more detail. These findings will then be discussed in the context of different methods used by researchers before moving to the significance of the unresolved attachment pattern in ED. Based on these data, we identify some interesting avenues for future research and outline the clinical implications for the assessment and treatment of adolescents with ED.

The existing literature examining attachment in adolescents with ED is small but a search of current research databases ( PsychINFO , Sciencedirect , Psychindex , and Pubmed ) reveals that the number of papers looking at this age group specifically has increased in the last years. Articles for inclusion in this review were identified from PsychINFO (1966–2013), Sciencedirect (1970–2013), Psychindex (1980–2013) and Pubmed (1980–2013). The search terms “ adolescence ,” “ eating disorders ,” “ anorexia nervosa ,” and “ bulimia nervosa ” were used as major descriptors. We only included articles which (1) stated the use of the search terms in the title, key words or abstracts, (2) are published in the English or German language in a peer-reviewed journal or book chapter and either (3) used a clinical sample including adolescents (≤ 18 years) or young adults or (4) a non-clinical adolescent sample with significant eating problems that are defined as sub-clinical degrees of disturbed eating behaviors and attitudes as well as body and weight dissatisfaction. As we need to keep the scope of this review contained and manageable, we only included studies using self-report questionnaires of attachment style (e.g., The Attachment Style Questionnaire; Experiences in Close Relationships Questionnaire) and narrative attachment measurements (AAI, AAP). We excluded studies that (1) only use self-report questionnaires assessing parental styles (e.g., The Parental Bonding Instrument) as they measure a concept that is different from attachment styles and patterns (for a recently published review on parental bonding in patients with ED, see Tetley et al., 2014 ) (2) focus on the period of childhood and preadolescence (< 12 years) (3) only include adult or older patients (> 24 years). Furthermore, we focus on AN, BN and EDNOS as the primary conditions in adolescents and therefore, we excluded studies solely concentrating on obesity, binge eating disorder (BED) or feeding disorders in childhood. Using the search terms mentioned above we found 81 published studies and 5 reviews on ED and attachment. From these 81 studies, 12 studies employ narrative techniques and 69 use self-report questionnaires to measure attachment. Furthermore, we identified 21 studies including an adolescent sample that will be reviewed in more detail. First, we will present age-specific findings from self-report adolescent studies and incorporate these results into the large body of research in adults. Then we will focus on the developmental approach and report on the major results concerning the unresolved attachment representation. Finally, we will outline implications for therapeutic intervention in adolescents and describe some interesting avenues for future attachment research in that age group.

Adolescent Attachment and ED Using Self-report Questionnaires

In recent years, an increasing number of researchers examining attachment in adolescents with ED have come to rely on self-report questionnaires of attachment. Self-report questionnaires either assess categories of attachment style or they measure the degree to which dimensions of attachment styles are present ( Ravitz et al., 2010 ). The outcome of self-report items is a product of thoughts about attachment that have entered the consciousness of a person and therefore reflect how the individual wishes to represent him- or herself toward others. Several self-report measurements like for example the Adult Attachment Questionnaire and the Experiences in Close Relationships converge on two dimensions of insecurity. Attachment anxiety refers to individuals with a negative sense of the self. They tend to expect separation, abandonment or insufficient love and they are preoccupied with the availability and responsiveness of others. Furthermore, they tend to maximize negative experiences, they are hypervigilant to potential threat and they demonstrate a hyperactivation of attachment behavior. In contrast, attachment avoidance refers to individuals with a negative sense of others. They are characterized by self-reliance, an avoidance of intimate relationships and they devaluate the importance of close relationships. In addition, they minimize feelings of distress and deactivate attachment behavior. To date, attachment studies using self-report questionnaires in adolescents have addressed fundamental questions about possible links between attachment styles, ED subtypes, symptom severity and treatment outcome.

The overall patterns of results across different studies provide strong evidence that there is a relationship between attachment classifications and ED. Collectively, findings from studies using self-report attachment questionnaires assessing secure, avoidant, anxious and for some measures fearful attachment styles (i.e., high insecurity on both attachment avoidance and anxiety) suggest that adolescents and young adults with ED have an insecure attachment style ( Orzolek-Kronner, 2002 ; Steins et al., 2002 ; Bäck, 2011 ). Some authors found a higher prevalence of the avoidant attachment style ( Ramacciotti et al., 2001 ; Latzer et al., 2002 ) and others found more anxious attachment styles in adolescent patients with ED ( Salzman, 1996 ; Tereno et al., 2008 ). Some authors speculated that an anxious attachment style characterized by a tendency for affective dysregulation might be associated with binge eating and purging behavior whereas avoidant attachment style characterized by a tendency to down regulate emotions might be linked to dietary restriction. However, the study results are not consistent concerning these associations suggesting that the diagnostic subgroup is not necessarily related to attachment insecurity dimensions ( Troisi et al., 2005 ; Strauss et al., 2006 ; Tereno et al., 2008 ; Illing et al., 2010 ; Dakanalis et al., 2014 ).

Thus, recent work in this field started to rather investigate links between adolescent attachment styles and symptom severity. This approach holds a good deal of promise for advancing our understanding of the psychopathological profile of patients with ED. Studies in young adults with AN and BN have already demonstrated that higher attachment anxiety was significantly related to greater ED symptom severity and poorer treatment outcome in patients with AN and BN ( Cash and Annis, 2004 ; Illing et al., 2010 ). A recently published study by Keating et al. (2015) has expanded this research by examining the influence of pre-treatment attachment insecurity on post-treatment depressive symptoms in adolescent and adult patients with ED. In their study, patients with a pre-treatment anxious attachment style demonstrated less reduction in depression than those with an avoidant attachment style. These results indicate that the increased need for approval and the hyperactivation of emotions in anxiously attached patients may impair their ability to develop useful coping strategies leading to a comparison with unrealistic standards. This is consistent with results from a growing number of studies demonstrating that hyperactivating strategies are mediators for attachment anxiety and depressive symptomatology in adolescents and adults ( Tasca et al., 2009 ; Malik et al., 2014 ). Even though these findings suggest that attachment anxiety influences symptom severity, only very little is known about the role of an insecure attachment style on the ED symptom change during and after treatment. Thus an interesting avenue for future research is to examine attachment-related predictors for short- and long-term outcomes in adolescents with AN. Furthermore, the aforementioned studies assessed attachment style only at pre-treatment and as studies from adults demonstrate that attachment can change after treatment it would be interesting to measure it at post-treatment as well ( Buchheim et al., 2008 , 2012a ; Smith and George, 2012 ; George and Buchheim, 2014 ; Salcuni et al., 2014 ).

In addition to these possible links between attachment styles, symptom severity and treatment outcome, researchers have become increasingly interested in how far attachment style represents a potential risk factor for developing an ED in adolescence. According to attachment theory, attachment styles have lasting implications for social information processing, emotion regulation and self-evaluative processes making individuals vulnerable to ED. Milan and Acker (2014) found that attachment insecurity is related to increased responsivity to individual (e.g., weight gain) and interpersonal (e.g., maternal negative affect) ED risk factors during adolescence. However, only few studies to date have addressed specific underlying cognitive and emotional processes explaining why attachment insecurity places adolescents at a greater risk for developing an ED. Demidenko et al. (2010) found that insecure attachment in adolescents is related to a poorer self-concept and lower identity differentiation—two dimensions commonly known as risk factors for developing an ED. Mindfulness seems to be another mechanism underlying this relationship ( Pepping et al., 2015 ). That is, individuals with an insecure attachment style are less capable to be aware of and accept the present moment without judging it leading to an impaired recognition of hunger and satiety as well less acceptance of the body and the self. Additionally, maladaptive perfectionism and problematic affect regulation seem to mediate the relationship between attachment insecurity and ED in adults ( Tasca et al., 2009 ; Dakanalis et al., 2014 ). To draw further conclusions on causal relationships, future studies should examine these associations longitudinally and find out in how far findings vary according to the stage of recovery. As all of the previously mentioned studies only include female participants, it remains unknown whether the same patterns of results would be observed in males.

In the last decades, a growing body of researchers has examined the role of the family for adolescents with ED. Some studies investigated in how far the relationship between parents and their children are related to the development of an ED in adolescents ( Troisi et al., 2005 ; Bäck, 2011 ). In one of the first studies examining attachment phenomena in adolescents with ED, Kenny and Hart (1992) found that parental fostering of autonomy and affectively positive and emotionally supporting parental relationships lead to less weight preoccupation, feelings of ineffectiveness and bulimic behaviors in young people. These results are consistent with subsequent literature findings concerning characteristics of parental relationships in ED patients ( Latzer et al., 2002 ; Bäck, 2011 ). Concerning the issue of parental relationships, Orzolek-Kronner (2002) hypothesized that ED behaviors like starvation, binge eating and purging might lead to close physical encounters between mothers and their daughters and thus increase physical and psychological proximity. In her study, adolescents with ED reported more proximity seeking behaviors than the clinical and non-clinical control groups. One unexpected finding emerging from this study was that adolescents with ED viewed their mothers as greater facilitators of independence compared to the control groups. This finding seem to be contradictory to earlier results demonstrating that undermining an adolescent’s autonomy striving might lead to more body dissatisfaction and greater risk for the development of ED symptoms ( Kenny and Hart, 1992 ; Latzer et al., 2002 ). Furthermore, there seems to be evidence of maternal and paternal overprotection and a higher amount of fragile, dependent mothers who strive toward a symbiosis with their ED daughters ( Tereno et al., 2008 ; Amianto et al., 2013 ). Thus the description of their mothers as supporting their autonomy might reflect the adolescents’ attempts to preserve the idealization of their primary caregiver. The idealization of parents is considered as a common feature of an avoidant attachment style and might explain why some authors have found a higher prevalence of this style in adolescent patients with ED ( Latzer et al., 2002 ).

In sum, the results found in these studies highlight the importance of attachment-related aspects for the etiology, psychopathological profile, treatment outcome and parental relationships in adolescents with ED (for details on the sample and measurements see Table 1 ).

Studies using self-report questionnaires in a sampleincluding adolescents with ED .

ECR, experiences in close relationships questionnaire; BSQ, behavioral systems questionnaire; AN, anorexia nervosa; BN, bulimia nervosa; ASQ, attachment style questionnaire; EDNOS, eating disorders not otherwise specified; RQ, relationships questionnaire; BED, binge eating disorder; AAS-R, adult attachment scale- revised; AAS, adult attachment scale; IPPA, inventory of parent and peer attachment; PAQ, parental attachment questionnaire.

While these investigations look at thoughts about attachment that have entered the consciousness of a person and therefore reflect how adolescents perceive themselves in relationships, they are not concerned with unconscious defensive processes and strategies which are essential for the developmental approach ( Ravitz et al., 2010 ; George and West, 2012 ). Using narrative techniques to assess developmental attachment patterns allows us to look beyond conscious thoughts of relationships and evaluate mental representations of attachment by analyzing patterns of responses when people talk about attachment situations. Employing these techniques might provide a deeper understanding of unconscious aspects of attachment-related defenses and behaviors and allow assessing attachment disorganization and trauma ( George and West, 2012 ; George and Buchheim, 2014 ).

Adolescent Attachment and Eating Disorders Using Narrative Techniques

The majority of the studies on attachment in adolescents and young adults with ED are using self-report measures and only very few make use of narrative techniques. The adult attachment interview (AAI; George et al., 1996 ) and the adult attachment projective picture system (AAP; George and West, 2001 , 2012) are two narrative interviews, which emphasize mental representations. These techniques allow analyzing unconscious defensive processes—a dimension which is lost in self-report measures. In the AAI individuals are asked to describe childhood and current experiences with their caregivers and recall specific attachment-related events. Secure individuals (F) are able to reflect and integrate positive and negative experiences with their caregivers and their evaluation of attachment experiences is coherent. In contrast to them, insecure-dismissing individuals (Ds) tend to idealize or devaluate their attachment experiences by deactivation of attachment distress. The insecure-preoccupied (E) group is enmeshed with their caregivers and they show anger and low autonomy in their narrative evaluation. Finally, the unresolved category (U) refers to individuals who show a breakdown of defensive and coping strategies when talking about traumatic experiences like loss and abuse. Their evaluation is incoherent and often includes fearful affect ( Buchheim and George, 2011 , 2012 ). The AAP is a narrative-based attachment measure that provides attachment classification based on the analysis of “story” responses to a set of theoretically-derived attachment-related drawings of scenes depicting solitude, illness, separation, death, and potential maltreatment. The AAP narratives of secure individuals (F) demonstrate the ability and willingness to think about attachment distress. In their stories characters reach out to attachment figures for comfort, they show a lot of constructive actions and they often describe mutual enjoyment in their relationships to others. The insecure-dismissing (Ds) group is characterized by a predominance of deactivating defensive processes that emphasize distance in relationships. Their narratives often focus on achievement and exploration. Attachment relationships usually provide functional care or they are described as authoritarian. The AAP stories of insecure-preoccupied (E) individuals include a lot of material that confuses and obscure attachment relationships. They typically concentrate on emotions related to problems, their responses have several undecided themes or story endings and they often focus on the past rather than on the present. This confusion in the story line is also reflected in the blurring of the hypothetical story with personal experiences. The unresolved attachment (U) refers to a group of individuals who are not able to contain and reorganize stories including features that evidence danger, helplessness, failed protection or isolation. Unresolved individuals become momentarily flooded by their attachment fears that cannot be reorganized in the narratives ( George and West, 2012 ).

To our knowledge, there are only eight studies using the AAI or the AAP in a sample including adolescents and young adults with ED ( Cole-Detke and Kobak, 1996 ; Salzman, 1996 ; Ramacciotti et al., 2001 ; Ward et al., 2001 ; Dallos and Denford, 2008 ; Dias et al., 2011 ; Lis et al., 2011 ; Sevecke, 2013 ) and interestingly, there are only three studies looking explicitly at adolescents ( Dallos and Denford, 2008 ; Lis et al., 2011 ; Sevecke, 2013 ). In the following paragraphs we are going to outline the main results of these studies by focusing on attachment strategies and underlying neurophysiological correlates in adolescents with ED before moving to the significance of the unresolved attachment status for this age group (for details on the sample and measurements see Table 2 ). In the final part of this section we discuss implications of these findings for future research.

Studies using narrative techniques in a sampleincluding adolescents with ED .

AN, anorexia nervosa; AAP, adult attachment projective picture system; BN, bulimia nervosa; EDNOS, eating disorders not otherwise specified; AAI, adult attachment interview.

In narrative-based attachment research, a number of studies have addressed the issue of attachment patterns in adolescents with ED using the AAI. Salzman (1996) investigated links among attachment patterns, affective instability and ED in young college women. Her most striking observation was that the insecure-dismissing attachment group showed the highest prevalence of ED. The dismissing daughters described the nature of the attachment to their mothers as “hot and cold,” “addictive love,” and a “push and pull relationship.” During the AAI, they focused on their mothers’ emotional inconsistency and they held their mothers responsible for their own distress. Furthermore, they mentioned unpredictable and hurtful attacks of their mothers on their self-image and social acceptability. At the same time they talked about moments of true understanding, i.e., when mothers are caring and offering the promise of a special connection. This paradox of longing for their mother on the one hand, and rejecting her on the other hand might be the trap that leads to affective dysregulation and an eating disorder. The starving might serve as a kind of nurturance that they cannot get from their mothers. It must be noted that although these results are based on a very small sample ( n = 7), they are consistent with the Ward et al. (2001) and Ringer and Crittenden (2007) findings of a push- and pull strategy for both denying any need for help and also seeking care. This interesting association between attachment patterns in adolescents and ED led to further investigations on attachment strategies in ED patients that define how individuals process distress-related memories in the AAI.

For example, Cole-Detke and Kobak (1996) examined attachment strategies in a sample of 44 college freshmen with clinically significant ED symptoms.. While a secure strategy means that a person can adaptively tolerate distressing childhood memories, defensive strategies develop when attachment figures are unavailable, insensitive or unresponsive. Researchers distinguish two subtypes of defensive strategies. The deactivating strategy develops when an individual perceives an attachment figure as rejecting or ignoring and therefore has to divert attention away from attachment distress. The hyperactivating strategy develops when attachment figures are perceived as inconsistently responsive and therefore individuals excessively focus on attachment-related information during the AAI which then results in passive or angry preoccupation ( Dias et al., 2011 ). When depression was statistically controlled, the authors found that young women with deactivating strategies were prone in reporting elevated levels of ED symptoms. It is assumed that these women have to shift their attention away from attachment toward more attainable goals like one’s appearance in order to win the approval of their emotionally unavailable and highly critical fathers. There are a couple of noteworthy limitations to this study. First of all, the study included a subclinical sample which limits the generalizability of the results. Second, the predominance of deactivating strategies among women with ED is mostly explained by the poor relationships to fathers but not to the mothers. Third, we have to keep in mind that a significant amount of women with ED symptoms also met depressive criteria ( n = 19). As there is a high comorbidity rate of depression in patients with ED, which would be associated with hyperactivating strategies during the AAI, future studies should address if there are differences between ED with and without psychiatric comorbidity in adolescence ( Salbach-Andrae et al., 2008 ; Hughes et al., 2013 ).

Underlying autonomic parameters of these attachment strategies in adolescents were investigated by Dias et al. (2011) . In their study they examined the physiological response of 47 women including adolescents with ED during the AAI. Interestingly they found that hyperactivating strategies were rather associated with the purging/binge eating group (BN, AN-binge eating/purging, BED and EDNOS with “chaotic” eating behavior) than with the restrictive group (AN-restrictive, EDNOS with high control/restrictive features). Concerning attachment patterns, 70% of the participants were classified as insecurely attached with a higher proportion of preoccupied individuals. On a physiological level these individuals displayed a higher electrodermal reactivity and cardiac reactivity when compared to the securely attached group. These results go in line with a number of other studies investigating the neurophysiological correlates of attachment during the AAI ( Beijersbergen et al., 2008 ; Holland and Roisman, 2010 ; Gander and Buchheim, 2015 ). The underlying autonomic parameters might suggest that patients with ED and an insecure attachment pattern feel more challenged when talking about early experiences. Furthermore, their emotion regulation strategies might be less productive when confronted with their own attachment experiences with caregivers. Interestingly, the heart rate variability was significantly correlated with attachment insecurity when they were asked to name five adjectives about the relationship with their fathers. Although these results extend previous work on autonomic correlates of adult attachment by including a clinical sample of patients with ED, the results must be interpreted with caution. The authors did not control for psychiatric medication which potentially could influence the physiological parameters and they did not use a control group to compare the results. Furthermore, both of the above mentioned studies did not include the unresolved category into their research. When looking at disorganized infants in the Strange Situation, we observe that they suffer from tremendous stress as indicated by high cortisol levels, increased heart rate and skin conductance ( Bernard and Dozier, 2010 ). Therefore an interesting avenue for future psychobiological attachment research is to identify and connect the moment of breakdown in unresolved individuals with recordings of physiological reactivity.

Currently, there are only a handful of published studies including the unresolved attachment category in a clinical sample of ED. In the following paragraphs we are going to discuss the main results of these studies and present one of the only studies focusing explicitly on adolescents.

The Role of the Unresolved Attachment Status (U) for ED

Narrative-based attachment studies indicate a high prevalence rate of the unresolved attachment category and provide an interesting insight into the nature of these traumatizing events. Furthermore, first studies demonstrate how attachment issues can be integrated into a multimethod assessment and be used for interventions in ED. Before launching into characteristics of the unresolved attachment classifications and its implications for the treatment in adolescents with ED, it is necessary to explore the role of trauma for this ED in general. It is well known that sexual and physical traumatization represent non-specific risk factors for the later development of an ED ( Jaite et al., 2012 ; Lejonclou et al., 2014 ). Practitioners who treat patients with ED often encounter histories of various traumatic and abusive experiences. With regard to the whole spectrum of traumatic experiences, patients with ED frequently report interpersonal trauma and adverse childhood circumstances like emotional abuse, mental health problems in parents or parental divorce during their upbringing ( Lejonclou et al., 2014 ). The results of different studies suggest that sexual trauma is associated more often with BN, AN-binge-eating/purging type and BED than with AN-restrictive type ( Brewerton, 2007 ; Jaite et al., 2012 ). However, only very little is known about the relationship between early traumatizing events and ED.

When it comes to attachment research, there are only very few studies looking at unresolved attachment representation in ED. In summary, studies including the unresolved attachment status indicate a predominance of this category in ED ( Ward et al., 2001 ; Ringer and Crittenden, 2007 ; Sevecke, 2013 ; Delvecchio et al., 2014 ; Von Wietersheim et al., 2014 ). One of the first studies examining the prevalence of an unresolved attachment status (U) was done by Fonagy et al. (1996) . They investigated the relationship between attachment patterns and psychiatric patients and found a high prevalence of U with respect to loss and abuse in the ED group. Although the sample size ( n = 14) is very small, it is an interesting result that 13 of the patients were classified as U when using the four-way attachment distribution of the AAI. Additionally, they found a high idealization of parents and low reflective functioning (i.e., the capacity to understand and reflect on mental states of the self and others) in these patients. When talking about attachment experiences, they never reflected on mixed emotions, conflict or uncertainty about feelings of others. Furthermore, their responses appeared somewhat clichéd, banal or superficial. This high prevalence rate of the U category could also be found in other studies using the AAI ( Ward et al., 2001 ; Zachrisson and Kulbotten, 2006 ; Ringer and Crittenden, 2007 ; Barone and Guiducci, 2009 ) and the AAP in anorexic and bulimic adolescent and adult samples ( Delvecchio et al., 2014 ; Von Wietersheim et al., 2014 ). In the study of Delvecchio et al. (2014) half of the adult anorexic patients were classified as U and 37% were classified as Ds. Interestingly, Sevecke (2013) assessed attachment representations with the AAP in inpatient adolescent girls with AN ( n = 34) and found that even 65% had an unresolved attachment status. These findings might suggest that adolescents with ED have an even higher prevalence of the U than adults.

A growing body of research has made notable strides in understanding specific characteristics of the unresolved attachment status by analyzing the narratives of ED patients. Delvecchio et al. (2014) found that the majority of anorexic women with an insecure or unresolved attachment classification reported a lot of traumatic material including eerie, evil or surreal elements in their response to the AAP picture stimuli. Ringer and Crittenden (2007) analyzed the content of AAI narratives in a larger sample of women with ED ( n = 67) and found a lack of resolution of trauma and loss related to the mothers and also hidden family conflict between the parents. One third of the daughters with ED were classified as unresolved concerning the following aspects: (1) fighting between the parents, (2) vicarious experience of a parent’s trauma or (3) an imagined relation between an event and ED. This is consistent with the results of the Dallos and Denford (2008) study. When examining the main areas of unresolved and traumatic processes in four families with anorexic daughters, they observed that one of their female anorexic adolescents showed a terrible fear that her parents might do something awful to each other. Yet interestingly, also the mother of this girl reported unresolved traumatic memories of her own depressed mother and her angry, unpredictable and abandoning father. Similarly, most of these unresolved traumas in the Ringer and Crittenden (2007) study were not based on a direct threat to the woman herself. Unfortunately, the parents’ AAI were not available for this study. However, in the discussion the authors comment on interviews of parents outside this sample that they have read. Surprisingly, the parents appear responsible and really caring for their daughters. However, during the AAI their mothers reported losses and severe dangers in their past (e.g., war, repeated sexual abuse, loss of a parent). The most outstanding feature of their discourse was their strong desire that their daughters are not affected by this. In other words, they wanted to protect their daughters from these unspeakable threats and disappointments of their own lives.

Ward et al. (2001) examined the attachment representations in mothers and their daughters with ED. Although this study had a small sample size (daughters n = 20, mothers n = 10), the high rate of the U category (67% of the mothers and 50% of the daughters) with respect to loss, particularly among the mothers, is quite striking. Now the question is in how far this affects the mother’s behavior. It can be hypothesized that although they seek a special closeness to their daughters and protect them from their own traumatic histories, they retreat or become unavailable in crucial moments when their daughters need them the most. Hardly anything is known about the nature of these traumatizing experiences in mothers. One possible traumatizing event in mothers was found by Shoebridge and Gowers (2000) . They observed a high frequency of obstetric losses (e.g., multiple miscarriages, stillbirth, early neonatal death) prior to the birth of their daughters who later on developed AN. Furthermore, there are no published studies looking at attachment using the AAI in fathers of these daughters with ED. Therefore an interesting avenue for future research would be to investigate a larger number of mother-daughter pairs/father-daughter pairs looking for transgenerational similarities. In addition, Barone and Guiducci (2009) found the unresolved attachment status only in patients ( n = 30) with BN and BED but not in AN. However, this unequal distribution also requires a replication using a larger sample to draw further conclusions.

Another interesting aspect is the integration of an attachment tool in a multimethod assessment in patients suffering from an ED. Lis et al. (2011) discussed the clinical implications using an attachment tool for a better etiological understanding and treatment plan. They presented a single case study of a 17-year old anorexic girl, who was classified as unresolved on the AAP. The in-depth analysis of the AAP indicates that she could not integrate and reorganize the pain and isolation she felt in relation to her illness and also the inability of her parents to provide comfort. Based on this preliminary finding, it would be an interesting avenue to analyze disorganized specific characteristics for ED patients and see in how far they differentiate from other psychiatric disorders. First studies looking at these aspects were already done for other psychiatric disorders like borderline personality disorder (PD), anxiety disorder, depression, PTSD and schizophrenia ( Buchheim et al., 2008 ; Buchheim and George, 2011 ; Juen et al., 2013 ). Such investigations would make important contributions to our understanding the complex etiology of ED in adolescence.

The aim of this article was to review the literature which examines the associations between attachment patterns and ED with a focus on adolescence. This approach is still a relatively untapped area of research. Most of the studies focusing on adolescents are using self-report measures, which directly assess an individual’s conscious appraisals of feelings and behaviors in close relationships but they cannot evaluate defensive processes when participants talk about their attachment experiences. In contrast, studies employing the AAI are underrepresented in the literature and they often only include small sample sizes as the interview procedure and the coding of this narrative instrument are very time-consuming. Another issue concerning the AAI is that it is valid for assessing loss through death and physical abuse which are important aspects of the unresolved attachment status. However, according to the AAI instruction guidelines interviewers rightfully should not ask for traumatic material that interviewees do not want to talk about. That is, if an interviewee fails to discuss traumatic experiences these are edited out of the AAI transcript ( George and West, 2011 ). The AAP is another narrative instrument that circumvents some of these potential practical drawbacks of the AAI as picture scenes serve as stimuli for the individual narratives and thus frightening memories might come up in the stories without being articulated as the interviewee’s own experiences ( George and Buchheim, 2014 ). In addition the AAP requires less time for administration and coding but at the same time shows an impressive agreement to the AAI. It also demonstrated acceptable validity for assessing attachment representation in adolescents and thus is amenable for use in a wide range of clinical settings including younger patients ( Buchheim et al., 2014 ).

Even though attachment is defined differently by the two approaches, the overall pattern of results from adolescent and adult samples suggest that most of ED patients are insecurely attached. One of the most striking results that emerge from narrative-based studies is the high prevalence of the unresolved attachment status in patients with ED and their mothers ( Ward et al., 2001 ; Ringer and Crittenden, 2007 ; Barone and Guiducci, 2009 ). This is particularly important for adolescents, as there seems to be considerable evidence for a higher prevalence of the unresolved attachment status in adolescent samples ( Sevecke, 2013 ) compared to adults ( Ringer and Crittenden, 2007 ; Lunn et al., 2012 ; Delvecchio et al., 2014 ). Research has already demonstrated that a mother’s unresolved trauma may lead to an impaired ability to sensitively respond to her child and thus may contribute to the transgenerational transmission of trauma ( Iyengar et al., 2014 ). However, the nature of these traumatizing experiences related to attachment is still an untapped area of research. Hence, a key priority for future research is to examine the nature of the trauma not only in adolescents with ED but also in their mothers. These investigations might broaden our understanding of the role of unresolved attachment status for an early onset of ED. Given that traumatized mothers also tend to superimpose their own needs on those of their daughters, one might expect that daughters remain dependent on their mothers to supply a sense of self as they have never learned to differentiate their own needs. However, studies unexpectedly found that adolescents with ED tend to idealize their parents and view their mothers as great facilitators of independence ( Orzolek-Kronner, 2002 ). In contrast, attachment studies in adults found more subjectively reported problematic mother-daughter relationships. They are characterized by a loving but at the same time neglecting, rejecting and role-reversing stance leading to an exaggerated display of angry feelings, an angry demand of the caregiver’s compliance and confusion regarding the parental behavior in their adult daughters ( Ringer and Crittenden, 2007 ; Barone and Guiducci, 2009 ). Replicating these findings using a longitudinal design would clearly be a promising area for future studies. Additionally, it appears that the role of fathers has largely been neglected in most of the studies using narrative techniques. A small number of studies have examined the attachment to fathers by using self-report measures (e.g., Parental Attachment Questionnaire, Parental Bonding Instrument, Inventory of Parent and Peer Attachment) in an adolescent sample with ED. The main findings show that patients feel more alienated from their fathers and they describe them as less caring and more controlling ( Orzolek-Kronner, 2002 ; Fujimori et al., 2011 ; Pace et al., 2012 ; Horesh et al., 2015 ). Therefore, it requires future studies including the fathers of patients to draw further conclusions on the dyadic nature of attachment in ED.

The question why attachment insecurity or disorganization places adolescents at a greater risk for developing an ED has received increasing attention in recent years. A growing number of studies found that insecure attachment style is related to a poorer self-concept, lower identity differentiation, lower acceptance of the own body and self and an impaired recognition of hunger and satiety. Regarding these risk factors in adolescence, studies from adults with ED demonstrate that additionally maladaptive perfectionism and personality characteristics like neuroticism and extraversion that manifest during early adulthood significantly mediate the relationship between insecure attachment style and ED in adults ( Eggert et al., 2007 ; Dakanalis et al., 2014 ). Future research on adolescent ED would profit by relating age-specific risk factors to different attachment patterns. An interesting question for subsequent studies is whether adolescents with an unresolved attachment status show a different amount and quality of risk factors that places them at a greater risk for an early onset than those who are insecurely attached. Furthermore, the higher prevalence of insecure attachment in adults raises fascinating questions about the role of romantic relationships for this age group. In how far attachment-related difficulties in intimate relationships represent potential risk factors or facilitate the maintenance of ED in adulthood has largely been unexplored in the research literature and thus represents an exciting research frontier for future studies ( Evans and Wertheim, 2005 ).

Another interesting question is in how far attachment classification can be linked to diagnostic subgroups of ED. One of the major problems is that past studies on attachment have tended to focus exclusively on AN and BN but studies on BED and obesity in adolescence are still rare. Moreover, the research to date demonstrates very controversial results due to the different methods employed in the studies. As the self-report questionnaires and the narrative instruments define attachment classifications in a different way, future studies should be careful when comparing their results as this might lead to confusion of terminology ( Ward et al., 2001 ; Ravitz et al., 2010 ; George and West, 2012 ). As suggested by O’Shaughnessy and Dallos (2009) it would be more helpful to examine if there is an association between attachment patterns and the symptom severity in ED. Yet, if future research is to identify these possible correlations we must also consider the high prevalence rate of comorbid disorders in ED like depression, anxiety and PD. In a very recent review on PD in adolescents with ED, Magallón-Neri et al. (2014) found that between 64 and 76% of adolescents with BN had a comorbid borderline PD or histrionic PD. In patients with AN the most common PD was the anankastic PD. Studies have demonstrated that the unresolved attachment classification predominates in borderline PD patients and thus the presence of a comorbid borderline PD might also have a significant influence on the attachment status of a patient with an ED ( Buchheim et al., 2008 ). Similar results were found in a preliminary study by Sevecke (2013) who investigated associations between attachment representations and PD in 34 adolescent patients with AN. Interestingly 65% of the girls were classified as unresolved on the AAP and even 82% fulfilled the criteria for a PD. The unresolved group showed a significantly higher PD comorbidity rate when compared to the other attachment groups. Furthermore, insecurely attached patients reported more borderline traits, self-harming behaviors, identity problems and greater emotional dysregulation.

In addition to that, studies have shown a significant association between trauma and a greater comorbidity in adolescents with ED ( Jaite et al., 2012 ). Based on these results, an interesting avenue for future research is to investigate the attachment-related mechanisms by which traumatic experiences, especially childhood maltreatment and interpersonal traumas, might lead to an ED in adolescence. Tasca et al. (2013) examined for the first time in how far attachment insecurity mediates the relationship between childhood trauma and eating pathology in a clinical sample of adults. Their findings indicate that attachment anxiety and avoidance measured with the Experiences in Close Relationships Questionnaire can partly explain this association between trauma and ED. To draw further conclusions, replication of this study using a narrative instrument to assess the unresolved attachment status and also analyze different affect regulation strategies associated with the different attachment patterns is needed ( Burns et al., 2012 ; Danner et al., 2014 ).

The clinical implications of the preceding issues on attachment in ED affect several practice areas, including the psychological assessment, case formulation and treatment of patients. Assessing a patient’s attachment pattern can not only provide new insights into the symptoms but also helps the clinician to predict the treatment outcome ( Buchheim et al., 2012b ; Salcuni et al., 2014 ). To put it differently, assessing different domains of attachment functioning (e.g., interpersonal style, affect regulation, unresolved mental states related to loss or trauma) allows the practitioner not only to address attachment-related goals for treatment, but also provides a template by which differential treatment approaches can be applied for each individual with an ED (for a detailed review, see Tasca, 2014 ). These new directions might result in better symptom outcomes, a higher treatment completion and an improved long-term interpersonal functioning.

The emerging body of attachment research in patients with ED provides us a promising insight into the interplay between environmental, social and individual factors and how they contribute to the development of this complex and painful condition. Although research in adolescents with ED is still at an early stage, first studies illuminate very interesting details about transgenerational aspects, unresolved trauma and loss, neurophysiological correlates of attachment and its implications for treatment and outcome.

The findings of this theoretical review illuminate relevant details about attachment related issues in adolescents with ED and their implications for assessment, case formulation and treatment. In our systematic analysis we found 13 studies using self-report measures of attachment and eight studies employing narrative instruments like the AAI and the AAP in an adolescent and young adult sample. Even though these two approaches measure different facets of attachment, the overall pattern of results from adolescent samples suggest that most of ED patients have insecure attachment. Results regarding links between diagnostic subgroups and the two different insecure attachment styles are not consistent. Some authors found a higher prevalence of the avoidant and others found more anxious individuals among adolescents with ED. The most striking result that emerges from the latest state of narrative-based research is the high prevalence of the unresolved attachment status in adolescent patients and their mothers. Only a small number of studies included fathers and they show that patients feel more alienated from them and they describe them as less caring and more controlling. Furthermore, recent studies demonstrate that adolescents with an unresolved attachment representation have a greater rate of comorbid disorders like PD and depression and higher ED symptom severity. Future studies that investigate traumatizing events, symptom severity and comorbidity in a larger sample of adolescents with ED using a narrative attachment measure might provide a better understanding and treatment of this complex and painful condition.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Abbreviations

adult attachment interview

adult attachment projective picture system

anorexia nervosa

binge eating disorder

bulimia nervosa

eating disorders

eating disorders not otherwise specified

personality disorder

unresolved attachment status.

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The landscape of eating disorders research: A 40-year bibliometric analysis

Affiliations.

• 1 School of Humanities and Social Science, The Chinese University of Hong Kong, Shenzhen, China.
• 2 School of Journalism, Fudan University, Shanghai, China.
• 3 Eating Disorder Assessment and Treatment Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
• 4 Department of Psychology, University of South Alabama, Mobile, Alabama, USA.
• 5 Department of Information Resource Management, School of Management, Tianjin Normal University, Tianjin, China.
• 6 School of Information Management, Wuhan University, Wuhan, China.
• PMID: 35040236
• DOI: 10.1002/erv.2884

Objective: Employing bibliometric methods, the present study aimed to map out the general landscape of existing research on eating disorders (EDs) over the past decades.

Method: Using the Web of Science database, we retrieved 41,917 research articles related to EDs published from 1981 to 2020. After removing those without an abstract, a total of 37,446 articles were retained. The study outlined the distribution of scholarship by time, languages, regions, and countries, and identified major research lines by applying latent topic modelling.

Results: Results revealed a general increasing trend in the number of publications on EDs research, and researchers from Western countries dominated the production of related scholarship. The distribution of published scholarship varied significantly by languages, regions, and countries. Seven main research topics emerged from past research (i.e., animal studies of food intake, risk factors and at-risk groups for eating disorders, body image in eating disorders, studies of cognition and brain in eating disorders, symptomatology and comorbidity of eating disorders, body weight and nutrition status in eating disorders, and treatment of eating disorders), with different topics showing unique research trends across the years.

Conclusions: This bibliometric analysis presents the most complete up-to-date overview on published research on EDs. While there is an increasing trend for EDs research, the available research evidence is generally from Western countries; thus, it is suggested that cooperation on EDs research should be strengthened between Western countries and other countries in the future.

Keywords: bibliometric analysis; citation analysis; eating disorders; latent topic modelling; research topics.

© 2022 Eating Disorders Association and John Wiley & Sons Ltd.

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Research Article

40 years of research on eating disorders in domain-specific journals: Bibliometrics, network analysis, and topic modeling

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation School of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima, Perú

• Carlos A. Almenara

• Published: December 15, 2022
• https://doi.org/10.1371/journal.pone.0278981
• Peer Review
• Reader Comments

Previous studies have used a query-based approach to search and gather scientific literature. Instead, the current study focused on domain-specific journals in the field of eating disorders. A total of 8651 documents (since 1981 to 2020), from which 7899 had an abstract, were retrieved from: International Journal of Eating Disorders (n = 4185, 48.38%), Eating and Weight Disorders (n = 1540, 17.80%), European Eating Disorders Review (n = 1461, 16.88%), Eating Disorders (n = 1072, 12.39%), and Journal of Eating Disorders (n = 393, 4.54%). To analyze these data, diverse methodologies were employed: bibliometrics (to identify top cited documents), network analysis (to identify the most representative scholars and collaboration networks), and topic modeling (to retrieve major topics using text mining, natural language processing, and machine learning algorithms). The results showed that the most cited documents were related to instruments used for the screening and evaluation of eating disorders, followed by review articles related to the epidemiology, course and outcome of eating disorders. Network analysis identified well-known scholars in the field, as well as their collaboration networks. Finally, topic modeling identified 10 major topics whereas a time series analysis of these topics identified relevant historical shifts. This study discusses the results in terms of future opportunities in the field of eating disorders.

Citation: Almenara CA (2022) 40 years of research on eating disorders in domain-specific journals: Bibliometrics, network analysis, and topic modeling. PLoS ONE 17(12): e0278981. https://doi.org/10.1371/journal.pone.0278981

Editor: Alberto Baccini, University of Siena, Italy, ITALY

Received: February 5, 2021; Accepted: November 27, 2022; Published: December 15, 2022

Copyright: © 2022 Carlos A. Almenara. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data that support the findings of this study are publicly available from the OSF repository: https://osf.io/5yzvd/ (DOI: 10.17605/OSF.IO/5YZVD ).

Funding: Funding for this study was obtained from Universidad Peruana de Ciencias Aplicadas (A-006-2021).

Competing interests: The author has no competing interest to declare.

Introduction

There are a large and growing number of scientific publications on eating disorders (ED) [ 1 – 3 ]. ED are mental disorders characterized by a continuous disturbance in eating behavior, such as Anorexia Nervosa [ 4 ]. ED are usually defined according to manuals like the Diagnostic and Statistical Manual of Mental Disorders (DSM) [ 4 ]. The spectrum of ED can share some symptoms (e.g., fear of fatness ), and these symptoms negatively impact psychosocial functioning and physical health. Due to the complexity of ED like Anorexia Nervosa, scholar literature about them covers different disciplines, such as ED related to: visual arts (e.g., art history) [ 5 ], sociology (e.g., social history) [ 6 ] and even dentistry (e.g., oral health) [ 7 ]. Thus, ED literature has a broad diversity.

Previous bibliometric studies about ED have focused on: identifying the distribution by language, region and country, as well as topics and their trends [ 1 ], productivity trends and collaboration patterns [ 2 ], most cited works in Anorexia Nervosa research [ 8 ], cross-cultural aspects of ED [ 3 ], comparison of citations between types of journals [ 9 ], female authorship [ 10 ], secular trends in the scientific terminology [ 11 , 12 ], the gap between scientific research and clinical practice [ 13 ], the use of keywords [ 14 ], and network analyses of common terms used in the field [ 15 ]. In particular, the current study complements the work by He et al. [ 1 ].

A standard practice of these studies is to retrieve the literature by performing a systematic search in databases like Web of Science or Scopus (i.e., employing a query-based approach), although there are some caveats worth mentioning. As noted elsewhere [ 16 , 17 ], those two databases differ in journal coverage and their use can introduce bias favoring science publications (e.g., biomedicine) in detriment of arts and humanities, other than overrepresenting English-language journals. Second, databases in general (including others like PubMed, Dimensions, JSTOR), differ in their search engine functionality and information retrieval capabilities.

For example, some databases offer a controlled vocabulary like a thesaurus or taxonomy from which to choose the search terms (e.g., the Medical Subject Headings [MeSH] in PubMed), whereas others offer a full text search. Regarding the latter, indexing scanned documents to offer a full text search, requires pre-processing methods like optical character recognition (OCR), known to include typos, and post-OCR processing, both affecting information retrieval accuracy [ 18 – 23 ].

In other words, a query-based approach, although widely used, can be affected by several factors, including: domain expertise to design the most appropriate search strategy, the characteristics of the selected database(s), including indexation accuracy (e.g., due to OCR typos). The former is particularly important because scholars are not always consistent in using the terminology [ 24 ]. In fact, their selection of keywords is not systematic, but rather influenced by factors like their background knowledge and previous experience [ 25 ]. In this regard, within the field of ED, scholars are encouraged to use appropriate terminology [ 26 , 27 ], usually a controlled vocabulary such as the Thesaurus of Psychological Index Terms. This helps to optimize the Knowledge Organization Systems (KOS) of journals and databases, such as a controlled vocabulary for information retrieval [ 14 , 28 ].

In sum, most previous studies have employed a query-based search, being compelled to choose among different databases, search terms, and search strategies [ 29 ]. Nevertheless, this approach not necessarily recognizes the boundaries and limitations of both databases and we as humans interacting with machines, using diverse information retrieval strategies, and dealing with information overload [ 30 , 31 ].

An alternative to the query-based approach is the one proposed in this study: to select a set of specialty journals exclusively devoted to the study of ED. Although this sampling could seem arbitrary, it was adopted: (1) to complement the findings of previous studies [ 1 , 2 ] and (2) because it has in fact a sound base: the intellectual and social structure of knowledge [ 32 – 36 ]. We must recognize that documents need to be understood with regard to "the broader contexts in which they are produced, used, and cited" [ 37 , p. 42]. Thus, the following sections will explain how domain-specific journals are tightly tied to an organized social and disciplinary structure. Moreover, I will explain how this approach does not necessarily exclude all ED literature from non-domain-specific journals, but rather incorporates part of it into their citations. Finally, from a complex systems perspective, I will show how domain-specific journals can be conceived as a specialized subset from the larger and more complex network comprising all ED literature.

Domain-specific journals and its social structure

From a scientometric perspective, science, metaphorically conceived as a knowledge space or knowledge landscapes , can be defined in terms of a network of scholars that produce a network of knowledge [ 35 ]. In the former case, the social function of science has long been recognized (e.g., by Thomas Kuhn): scholars produce and communicate scientific knowledge and this organized activity has the characteristics of a social process [ 36 , 38 ]. More importantly, the patterns of interactions and communication within this social organization are tightly tied, rather than isolated, to the knowledge they produce [ 36 ].

An exemplary case is the role of journal editors as gatekeepers, with studies identifying editorial gatekeeping patterns [ 39 , 40 ]. According with the Network Gatekeeping Theory, inspired by the work of Kurt Lewin, gatekeeping refers to the control in the flow of information [ 41 , 42 ]. In the field of ED, this intellectual and social organization of knowledge can be seen in professional societies like the Academy of Eating Disorder, which since 1981 publishes the most renowned scientific journal: The International Journal of Eating Disorders. Within its editorial board, there are distinguished scholars that can act as gatekeepers to ensure quality control and that manuscripts published by the journal are in line with the aims and scope of it.

In sum, domain-specific journals have the goal of publishing information within the boundaries of their aims and scope, allowing the diffusion of specialized knowledge.

Domain-specific journals and its disciplinary organization

From a network perspective, specialty journals are also indicators of disciplinary organization [ 43 ], which exerts a non-trivial influence at both the global and local level of the network. To be more precise, if we visualize a network [e.g., 2 , 44 , 45 ], the local density of specialty journals evidence emerging patterns such as citation patterns by articles from the same journal or group of journals [ 43 ]. At the author level, these patterns reflect the local influence of specialty journals on scholars who adhere to their research tradition and their contributions help to advance a research agenda [ 46 ].

For example, domain-specific journals on ED often publish curated information from conferences [e.g., 47 ] or special issues about a specialized topic [e.g., 48 ], which commonly include a research agenda [ 48 ], setting the stage for future research. As we mentioned above, similar literature, such as special issues about ED published in other journals [e.g., 49 ], is not necessarily excluded in the analysis of domain-specific journals. Rather, such literature is commonly cited in documents from domain-specific journals and can be included in a citation analysis. Importantly, these citation patterns suggest that the former intellectual and social structure of knowledge constrains what is being studied in the future [ 46 ]. Thus, in the upcoming years, most of this specialized literature is expected to become an active research front [ 32 ], as evidenced by its high number of citations.

Finally, it is worth mentioning that the analysis of these patterns can reveal latent hierarchies and topological properties of journal networks. In fact, domain-specific journals can be identified through the study of the hierarchical organization of journal networks. When hierarchical network analysis is used to identify the capability of journals to spread scientific ideas, multidisciplinary journals are found at the top of the hierarchy, whereas more specialized journals are found at the bottom [ 50 , 51 ]. Similarly, significant articles from a specific domain have unique topological properties that can affect the dynamic evolution of the network [ 52 ]. In sum, it is important to recognize the topological properties of networks and their latent hierarchies, both at the journal level and document level. In our case, focusing on domain-specific journals, it would be like zooming into the most central part (core) of the network topology to analyze its organization and distinctive features. Indeed, this approach is commonly employed, for example, when studying network subsets such as niches or communities in complex systems.

Domain-specific journals and complex adaptive systems

Domain-specific journals can also be comprehended from a complex systems standpoint, as the aggregation of the intellectual, social, and citation patterns outlined above. According to the Structural Variation Theory [ 53 ], the body of scientific knowledge can be conceived as a complex adaptive system (CAS). As such, it can be described and studied as a complex network with a series of characteristics like non-linearity, emergence, and self-organization; and a series of social, conceptual, and material elements that evolve over time [ 46 ]. Ideally, we must study CAS holistically to understand the properties of the system at the macrolevel [ 54 ]. In our case, this would require including all scholar literature on ED, which could be attempted using a query-based approach and employing ad hoc methodologies (e.g., iterative citation expansion) [ 45 ]. However, complex systems emerge from rules and behavior of lower-level components, and there is growing interest in understanding complexity from its simplest and fundamental elements and patterns [ 55 , 56 ]. In our case, this can be accomplished by zooming into domain-specific patterns that emerge from the relational structure and organization of journals and papers [ 46 ], rather than focusing on the whole system which comprises all the scientific literature on ED.

This approach can be described in terms of modularity , a structural property of systems: the local density of specialty journals is indicative of a structural module or subsystem [ 57 ]. This property of complex systems is important because it recognizes, as we did above, the existence of subsets within networks. Indeed, scientometric studies usually attempt to detect communities based on the principle of modularity by grouping similar literature (i.e., clustering) [ 44 , 58 ]. However, in the approach used in this study, rather than using bibliographic connections (e.g., through co-citation analysis) to detect domain-specific literature, we can use logical connections [ 59 ], to identify modules that operate as domain-specific representations [ 60 ]. In other words, domain-specific journals can be seen as clusters of articles that are logically linked because they all pertain to a given domain, which is explicitly stated in the aims and scope of the journals.

This modular organization has some advantages over others such as a hierarchy (e.g., Scimago categorization of journals) or a cluster obtained by literature partitioning algorithms. First, it has the advantage of reducing both complexity bias and hierarchical bias . The former is the tendency to assume and adopt a more complex system (the opposite to Occam’s Razor: prefer the simplest explanation), which means to analyze all ED literature. The latter assumes that behavior is directed in a hierarchical fashion, where a central authority passes instructions to all agents in the system [ 54 ]. Second, although it still recognizes a hierarchical structure composed by diverse classes of subsystems, it assumes heterarchy [ 43 , 61 ], which means that both hierarchical and nonhierarchical elements can be present in a system; holarchy , which means that systems are composed of components that can be recognized as subsystems [ 62 ]; and glocal control , which means that local and global phenomena in a system are achieved by local actions [ 63 ]. In simple words, sampling a set of domain-specific journals reduces complexity without affecting assumptions such as a categorical hierarchy of journals.

The current study

To expand on previous studies [ 1 , 2 ], the current study aims to answer the following research questions:

Which are the most cited documents in this domain-specific corpus of articles?

Which are the most important authors and their collaboration networks?

Which are the most relevant topics in this domain-specific corpus of articles?

How have the identified topics evolved over time (since 1981 to 2020)?

To answer these questions, this study employs a hybrid methodology. First, basic bibliometrics will be performed to identify the most cited documents. Second, network analysis will be employed to identify the most important authors and their networks of collaboration. Third, text mining, natural language processing, and machine learning algorithms will be used to identify the most relevant topics (i.e., topic modeling). Finally, a simple time series analysis will be performed to examine the evolution of these topics over time. The procedure employed for the analyses is detailed in the methods section below (and S5 File ), whereas the dataset and the code to perform the analyses are shared in a public repository ( https://doi.org/10.17605/OSF.IO/5YZVD ), allowing the reproducibility of results [ 64 ].

Data collection

The methodology workflow is presented in Fig 1 .

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• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0278981.g001

First, in May 2020, a search of journals was performed in Scimago Journal Reports (SJR, https://www.scimagojr.com/ ), using the term “eating disorders”. In this step, the following five journals were identified: International Journal of Eating Disorders (ISSNs: 0276–3478, 1098-108X), European Eating Disorders Review (ISSNs: 1072–4133, 1099–0968), Eating Disorders (ISSNs: 1064–0266, 1532-530X), Eating and Weight Disorders (ISSNs: 1124–4909, 1590–1262), and Journal of Eating Disorders (ISSN: 2050-2974). The official website of each journal was then visited to confirm that the scope of the journal specifically includes the publication of research articles on eating disorders. It should be noted that the journal Advances in Eating Disorders (ISSNs: 2166–2630, 2166–2649) was not included because it was not found in SJR, it was published only between 2013 and 2016, it was incorporated into the journal Eating Disorders , and by the time of writing this article, it was not indexed neither in Scopus ( https://www.scopus.com ) nor in Web of Science ( https://www.webofknowledge.com ).

Next, also in May 2020, the Scopus database was chosen to retrieve the document records from the aforementioned journals. The election was made for no other reason than the capability of Scopus to retrieve several structured information (metadata, such as the abstract), and the file types for download are easy to manage, such as comma-separated values (CSV). Therefore, all document records published by these journals were searched in Scopus using the ISSN as the search term (e.g., ISSN (0276–3478) OR ISSN (02763478) OR ISSN (1098-108X) OR ISSN (1098108X) ). A total of 8651 documents between 1981 and 2020 were retrieved (of which 7899 had an abstract): 4185 (48.38%) from the International Journal of Eating Disorders, 1540 (17.80%) from Eating and Weight Disorders, 1461 (16.88%) from the European Eating Disorders Review, 1072 (12.39%) from Eating Disorders, and 393 (4.54%) from the Journal of Eating Disorders. These 8651 documents included a total of 213,744 references. It should be noted that the International Journal of Eating Disorders is the oldest of these journals, established in 1981. The S7 and S8 Files provide the number of documents per year and per journal. The document records were downloaded from Scopus both as comma separated values (CSV) and as BibTex ( http://www.bibtex.org/ ), and selecting all fields available (i.e., title, author, abstract, etc.). Due to copyright, the full text of all documents was not retrieved but rather their metadata (i.e, title, author, date, abstract), whilst the dataset shared online ( https://doi.org/10.17605/OSF.IO/5YZVD ) is the one obtained after the preprocessing procedures detailed below.

Analyses were performed using open software: R Statistical Software 4.0.3 (Bunny-Wunnies Freak Out) [ 65 ], and Python programming language version 3.9.1 ( https://www.python.org/ ).

Bibliometric analysis and network analysis in R

The biblioshiny application from the R package bibliometrix [ 66 ] was used to preprocess the CSV file. Next, it was used to identify the most cited documents. Local citations (i.e., citations only from documents whithin the dataset), and global citations (i.e., citations made by any document from the whole Scopus database), were computed. Biblioshiny was also used for network analysis as described by Batagelj & Cerinšek [ 67 ], and Aria & Cuccurullo [ 66 ]. Regarding the network, it is defined as a pair of sets: a set of nodes or vertices and a set of edges (link between nodes) [ 68 ]. In this study, when authors were treated as nodes, a link would represent co-authorship or collaboration [see 69 ]. More precisely, the Louvain algorithm for community detection [ 70 ] was used to identify communities within the collaboration network. This algorithm identifies densely connected nodes within the network (i.e., communities) [e.g., 71 ]. It works unconstrained to automatically extract a number of clusters although it requires basic network parameters as input. These network parameters were: up to 100 nodes, a minimum of two edges by node, and the removal of isolated nodes. For network layout visualization, the Fruchterman & Reingold [ 72 ] algorithm was chosen. Finally, common centrality measures were calculated: betweenness, closeness, and PageRank. Betweenness centrality refers to “the frequency that a node is located in the shortest path between other nodes” [ 73 , p. 772]. Closeness centrality refers to nodes that can easily reach others in the network, whilst PageRank , originally created to rank websites [ 74 ], has been used to rank authors because it takes into account the weight of influential nodes [ 75 ].

Topic modeling: Dimensionality reduction and matrix factorization

As can be seen in the workflow ( Fig 1 ), once network analysis was finished, a series of steps (detailed in S5 File ) were necessary to preprocess the dataset prior to topic modeling. Topic modeling refers to applying machine learning techniques to find topics by extracting semantic information from unstructured text in a corpus [ 76 ]. As we explain in S5 File , to this point we end up with a high-dimensional and sparse document-term matrix. In other words, we have many features (columns) each corresponding to a term in our corpus, and for a given document (rows) we have many columns with zero values meaning the term of that column is not in the given document. To deal with sparsity, we can perform dimensionality reduction to obtain a representation that effectively captures the variability in the data. In summary, dimensionality reduction can be categorized in feature extraction and feature selection ; the former combines the original feature space into a new one, whereas the latter selects a subset of features [ 77 ].

As explained in S5 File , the term frequency (TF) and the term frequency-inverse document frequency (TF-IDF) were used as feature extraction for vectorization. Then, the following machine learning algorithms were applied for topic modeling: Latent Dirichlet Allocation (LDA) [ 78 ], Latent Semantic Analysis (LSA or Latent Semantic Indexing) [ 79 ], Hierarchical Dirichlet Process (HDP) [ 80 ], and Non-negative Matrix Factorization (NMF) [ 81 ]. LDA is a generative probabilistic model that decomposes the document-term matrix into a topic-term matrix and a document-topic matrix, and it is commonly used for topic discovering from a corpus [e.g., 82 ]. LSA utilizes a truncated Singular Value Decomposition for decomposition and can work efficiently on TF or TF-IDF sparse matrices. In a fully unsupervised framework, the HDP model is characterized by inferring the number of topics on its own. Finally, NMF is an alternative approach that implements the Nonnegative Double Singular Value Decomposition, an algorithm suitable for sparse factorization [ 83 ].

First, the GENSIM library [ 84 ] was used for topic modeling because it provides a way to calculate topic coherence , an index to compare models based on measures of segmentation, probability estimation, confirmation measure, and aggregation [see 85 ]. Therefore, based on a TF matrix, HDP, LSA, NMF, and LDA were performed in GENSIM and compared in topic coherence. Once identified the topic modeling algorithms with the highest topic coherence, scikit-learn [ 86 ] was used because it provides an Exhaustive Grid Search option for ensemble learning the models (i.e., automatically fine-tuning the parameters to find the most optimal). Finally, once the topics were extracted, a simple time series analysis was performed to visualize the changes over time in the topics found. This analysis consisted of simply plotting the number of documents for each topic across years, from 1981 to 2020.

First, bibliometric analyses were performed to identify the most cited documents. Local citations are presented in Table 1 (and the S1 File ), whereas global citations are in Table 2 (and the S2 File ).

https://doi.org/10.1371/journal.pone.0278981.t001

https://doi.org/10.1371/journal.pone.0278981.t002

Next, a network analysis was performed to identify the most important authors ( Table 3 ) and their collaboration networks ( Fig 2 , see also S3 File , a dataset, and S4 File , an interactive visualization in HTML and JavaScript, also available online: https://osf.io/5yzvd/ ). This collaboration network analysis identified eight clusters with 96 authors: (1) red color, 4 authors; (2) blue, 15 authors; (3) green, 17 authors; (4) purple 21 authors; (5) orange, 2 authors; (6) brown, 18 authors; (7) pink, 2 authors; (8) grey, 17 authors.

https://doi.org/10.1371/journal.pone.0278981.g002

https://doi.org/10.1371/journal.pone.0278981.t003

Regarding the most relevant topics, LDA and NMF were superior to HDP and LSA in topic coherence. Then, when ensemble learning was used for LDA (based on TF) and NMF (based on TF-IDF), NMF provided the most meaningful results, and 10 topics were identified ( Table 4 ).

https://doi.org/10.1371/journal.pone.0278981.t004

The labels for the topics were manually added based on the top 10 keywords and their respective weights. Thus, each topic was manually labeled as follows: (1) risk factors for eating disorders, (2) body image dissatisfaction, (3) Binge Eating Disorder diagnosis, (4) weight loss, weight control, and diet, (5) clinical groups, (6) treatment outcome, (7) family and parent-child, (8) binge and purge episodes, (9) gender and subgroups, (10) EDNOS.

To examine how these topics have evolved over time, a simple time series analysis plot was created ( Fig 3 and S6 File ).

Note . Values in the y-axis are the sum of the weight values from the NMF analysis for topic dominance, per year and per topic. Values go from minimum 0 to maximum 11.2 (see S6 File ).

https://doi.org/10.1371/journal.pone.0278981.g003

This study analyzed 8651 documents between 1981 and 2020 from domain-specific journals in the field of eating disorders. The aims were: to identify the most cited documents, the most important authors and their collaboration networks, and the most relevant topics and their evolution over time. The results expand previous findings of studies that employed a query-based approach and included articles dating back as far as 1900 [ 13 ]. In particular the results expand the studies by Jinbo He et al. (2022) and Juan-Carlos Valderrama-Zurián, et al. (2017), which employed a similar methodology [ 1 , 2 ]. For example, He et al. (2022) created a collaboration network, although it was based on countries rather than authors [ 1 ]. Therefore, the results obtained here (e.g., author centrality measures, author clusters) provide a more fine grained understanding of the relevance and contribution of individual authors and their collaboration networks. Furthermore, He et al. (2022) [ 1 ] identified top authors based on traditional performance metrics (e.g., h-index), and it should be noted that there is some criticism towards their use and a claim to shift towards more responsible metrics of research excellence [ 87 ]. Then, He et al. (2022) [ 1 ] employed LDA for topic modeling, whilst this study employed NMF. Although LDA is largely used, in this study NMF outperformed LDA in interpretability, reproducibility, and as we said above, it suits better for short texts, as is the case of article abstracts used here. Finally, the top journals identified by He et al. (2022) confirmed that the five journals selected for this study are in fact among the most important in the field of eating disorders [ 1 ]. In the case of Valderrama-Zurián, et al. (2017) [ 2 ], they also focused on authors’ productivity trends whereas their social network analysis was focused on network metrics such as the number of nodes and edges over time, which precludes to inspect the social network at the author level. Therefore, this study also expands on the findings of Valderrama-Zurián, et al. (2017) [ 2 ].

Below, we discuss in more detail the results of the analysis employed to answer the four research questions outlined in the introduction.

Bibliometric analysis

The top cited documents were all from the International Journal of Eating Disorders. As noted above, this journal is the oldest one (it started in 1981), and it has the largest number of articles per year, with the exception of the year 2019 when it was outperformed by the Eating and Weight Disorders journal (see S7 and S8 Files). The majority of top cited documents were related to the development of instruments for the assessment of eating disorders or the course and outcome of eating disorders. For example, we can see in the results the most common instruments used for the screening of eating disorders, as well as the evaluation of its core symptoms: Eating Disorder Inventory (EDI), Body Shape Questionnaire (BSQ), Dutch Eating Behavior Questionnaire (DEBQ), and Eating Disorder Examination Questionnaire (EDE-Q). These instruments are widely used to screen the general population, as well as in clinical settings, together with more recent instruments [ 88 ]. It should be noted, however, that in clinical practice settings the use of instruments for the diagnosis and the different phases of the treatment process is not necessarily widespread [ 89 , 90 ]. To reduce this gap, some authors suggest to provide assessment training and/or assessment guidelines for mental health professionals and general practitioners in primary health care [ 91 , 92 ]. This can help obtain a comprehensive clinical assessment, particularly of individuals with higher risk such as young adolescents with restrictive Anorexia Nervosa [ 93 ]. The instruments mentioned above are reliable measures, and they could be used online for a quick screening or session by session for ongoing monitoring, although further research is necessary [e.g., 94 – 96 ].

The rest of most cited documents include important review articles on epidemiology (Hoek & van Hoeken, 2003, in Table 1 ); the course and outcome of eating disorders (Berkman, Lohr & Bulik, 2007; Strober, Freeman & Morrell, 1997; in Table 1 ); and the diagnosis of Binge Eating Disorder (Spitzer et al., 1992, 1993, in Table 1 ). These results are similar to previous studies in which measurement methods (including instrument development), epidemiology, and review articles were the most common type of document [ 8 , 9 ].

Finally, the large number of articles on the diagnosis of Binge Eating Disorder, which was not fully recognized as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until its fifth edition [ 4 ], reveal that the recognition of Binge Eating Disorder as an own disorder took several years. To reach expert consensus in a shorter time, eating disorder professionals should pay special attention to emerging eating problems, such as Orthorexia Nervosa [ 97 ].

Network analysis

The network analysis identified eight clusters with 96 authors. Previous studies have examined the network of authors in the field in terms of network statistics such as number of edges or network density [ 2 ]. By contrast, this study provides a more fine-grained network analysis, identifying experts and group of experts in the field of eating disorders. As seen in the results section, the majority are distinguished authors with contributions dating back to the early 1980s.

The author with the largest betweenness centrality was Ross D Crosby (Sanford Center for Biobehavioral Research, United States), followed by James E Mitchell (University of North Dakota, United States) which has the largest value in PageRank. Authors with high betweenness centrality can act as both enablers and gatekeepers of information flow between communities [ 75 ]. Moreover, it has been found that authors with high betweenness centrality establish more collaborations than those high in closeness centrality [ 75 ]. In summary, the results of centrality measures can help to identify experts in the field of eating disorders, particularly authors that can quickly reach other authors in the network (high in closeness), act as gatekeepers (high in betweenness), or relate to influential others (high in PageRank).

Regarding the clusters identified by the network analysis, in the same cluster of Ross D Crosby and James E Mitchell are found other renowned authors like Daniel Le Grange (University of California, San Francisco, United States), Stephen A Wonderlich (Sanford Center for Biobehavioral Research, United States), and Carol B Peterson (University of Minnesota, United States). Among the most relevant results of collaboration of this cluster we can find studies on the ecological momentary assessment of eating disorders [ 98 ], the psychometric properties of the EDE-Q [ 99 ], and the diagnosis of Binge Eating Disorder [ 100 ].

The second largest cluster includes authors like Cynthia M Bulik (University of North Carolina at Chapel Hill, United States), Walter H Kaye (University of California, San Diego, United States), and Katherine A Halmi (Weill Cornell Medical College, United States). The results of their collaboration include studies related to the phenotypic characterization of eating disorders, such as the International Price Foundation Genetic Study, a multisite study that included a large sample of patients with eating disorders and their families [e.g., 101 ].

Finally, the third largest cluster includes authors like Janet Treasure (King’s College London, England), Ulrike Schmidt (King’s College London, England), and Tracey D Wade (Flinders University, Australia), which are widely recognized by the Maudsley Model for Treatment of Adults with Anorexia Nervosa (MANTRA) [ 102 , 103 ]. Interestingly, this is the only cluster that includes collaborations with authors from non-English speaking countries, more specifically from Spain. Examples of these collaborations include studies resulting from the Wellcome Trust Case Control Consortium 3 (WTCCC3) and the Genetic Consortium for AN (GCAN) [ 104 ], and other studies with clinical samples in Spain [e.g., 105 ].

On the other hand, the results reveal the importance of multisite studies that strengthen collaboration and originate in relevant outcomes for the prevention and treatment of eating disorders. Research groups could look for opportunities to collaborate in multisite studies and strengthen both their interdisciplinary and transdisciplinary collaboration, and their collaboration with less common partners such as stakeholders and policy makers [ 106 , 107 ]. By establishing these integrative and strategic collaborations we can promote translational research, and thus helping to reach broader public health goals [ 108 ].

Topic modeling

The combination of TF-IDF and NMF provided meaningful results, identifying 10 topics. After labeling these topics based on the first 10 keywords and their respective weights, we can see that most of the research on eating disorders done in the past 40 years has focused on their prevention and treatment. Interestingly, the time trend analysis of these topics revealed a noticeable change in the first lustrum of the 1990s. Whereas during the early 1980s the study of clinical groups (topic 5) was the most dominant topic, from the mid-1990s, this topic was surpassed by the study of risk factors of eating disorders (topic 1). This indicates an increasing interest for the prevention rather than solely the treatment of eating disorders. This result is consistent with the historical shift that occurred in the United States when in 1992 the Institute of Medicine (IOM) Committee on Prevention of Mental Disorders was created [ 109 ]. Then two years later, a report on reducing risk factors for mental disorders and promoting a preventive approach in research was published [ 110 ]. As expected, this shift had echo in several scholars at the time, became a research front, and relevant publications started to include more information on the prevention of eating disorders, including a special issue [ 111 ], book chapters [ 112 ], and progressively entire books [ 113 ]. It is important to note that this historical shift, as well as later others like in 2017 [ 114 ], were favorable, because in other cases like obesity, it took more time to focus on its prevention due to different issues, including the pressure of the weight loss industry and its commercial interest [ 115 ].

Another interesting finding was that the outcome of the treatment of eating disorders (topic 6), is the second most important topic of 2013, and this finding has important aspects to discuss. First, the surge of state-of-the-art machine learning algorithms provide several opportunities to build intelligent systems for precision medicine. Thus, the treatment course and outcome of eating disorders can be more personalized, guided, and enhanced with the help of predictive technologies and intelligent systems [e.g., 116 ]. Second, as suggested elsewhere [ 117 ], the advantages of technology can be particularly relevant for certain age groups like adolescents, and when a digital intervention is employed [ 118 ]. In summary, treatment outcome is currently an important topic, and future studies can deploy digital interventions and machine learning algorithms for a more precise treatment planning.

Limitations and conclusions

Although this study has strengths, such as using data and code that allows the reproducibility of the results, readers should consider some limitations. First, the analysis of most cited documents is for all the time span, and more recent highly cited documents are underrepresented. Moreover, the journal Advances in Eating Disorders was not included due to indexing issues. Nevertheless, this study provides the code and a detailed procedure to allow researcher to perform further analyses, such as document co-citation analysis. Future studies can also evaluate the Mexican Journal of Eating Disorders ( Revista Mexicana de Trastornos Alimentarios , ISSN 2007-1523), which has published articles primarily in Spanish [ 119 ]. Second, the network analysis included close to 100 scholars mostly with a long trajectory in the field, and this can be a limitation in representing more younger scientists or newcomers [ 2 ]. Future studies can focus on a larger number of scholars and apply different techniques in network analysis, such as other community detection techniques [e.g., 120 ]. Finally, the results of topic modeling suggested a solution of 10 topics out of up to 30 topics solution models tested. Although there is not a universally accepted approach to establish the number of topics, this study relied on several strategies, including ensemble learning, to automatically fine-tune the parameters of the machine learning algorithms, stability, and heuristic approaches [ 121 ]. Future studies can try other machine learning algorithms and techniques to retrieve topics [ 121 ].

In conclusion, this study analyzed 40 years of research on eating disorders, identified the most cited articles, networks of collaboration, experts in the field, and the 10 major topics in the field.

Supporting information

S1 file. most local cited documents..

https://doi.org/10.1371/journal.pone.0278981.s001

S2 File. Most global cited documents.

https://doi.org/10.1371/journal.pone.0278981.s002

S3 File. Network statistics.

https://doi.org/10.1371/journal.pone.0278981.s003

S4 File. Network of collaboration including close to one hundred authors.

https://doi.org/10.1371/journal.pone.0278981.s004

S5 File. Data preprocessing and text representation in Python.

https://doi.org/10.1371/journal.pone.0278981.s005

S6 File. Sum of NMF results for topic dominance per year and per topic.

https://doi.org/10.1371/journal.pone.0278981.s006

S7 File. Number of documents per year and per journal.

https://doi.org/10.1371/journal.pone.0278981.s007

S8 File. Trends over time in number of documents per journal.

https://doi.org/10.1371/journal.pone.0278981.s008

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• Open access
• Published: 27 January 2022

The future of eating disorders research: an editorial

• Stephen Touyz 1 &
• Phillipa Hay 2  

Journal of Eating Disorders volume  10 , Article number:  10 ( 2022 ) Cite this article

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Much has changed since the first months of 2020 when we penned one of the first editorials to be published on COVID-19 and how it might impact on those with the lived experience of an eating disorder. At that time as Editors-in-Chief of the Journal of Eating Disorders , we instigated one of the first themed special issue entitled “Eating Disorders in the time of COVID-19 outbreak—Implications for now and the future”. The number of papers submitted and since published has exceeded all anticipations, demonstrating the attention that has been directed to this important topic and the emergence of systematic reviews [ 1 ]. There can now be no doubt that this pandemic has had a devastating impact on those with the lived experience of eating disorders with distress calls to the Butterfly Foundation phone hotline in Australia and similar access points around the globe soaring to a height of almost 200% in the UK [ 2 ]. We in no way want to detract from the urgency in ensuring that all of those experiencing distress from an eating disorder and wanting treatment, succeed in doing so despite the lockdowns and self-isolation imposed by health orders. On the other hand, however, the opportunities that COVID-19 has presented in terms of innovative health care delivery should be grasped at a time in our history when we have witnessed the greatest transformation in the innovation of advanced digital technologies. Such technology was responsible for the launch of the world’s first ever open access journal dedicated to eating disorders on the 22nd January 2013. It is hard to believe that a decade has elapsed since that time and that in 2022, the Journal of Eating Disorders will be in its10th year.

Looking over the topics of those publications that appeared in early years of this journal, there is clearly an ever greater need for research in our field. Those working in the field of family based treatments for adolescents with eating disorders particularly anorexia nervosa are exploring new avenues to develop better clinical efficacy such as multiple family therapy [ 3 , 4 ], family based treatment (FBT) in the home, and combining FBT with dialectical behaviour and other therapies (see [ 5 ]). There has been precious little research to date that has transformed treatments for adults with eating disorders who are presenting much more of a challenge to those researching this field. In a recent Lancet Psychiatry meta-analyses of all the relevant randomised controlled trial research data on the role of cognitive behaviour therapy (CBT) in adult anorexia nervosa (AN), the authors concluded that in terms of outcome, it was not superior to treatment as usual [ 6 ]. Those venturing into novel areas for AN deserve our highest praise as it does take courage and fortitude to revisit theoretical understandings and venture into new avenues of neuro-modulation such as deep brain stimulation and rapid Transcranial Magnetic Stimulation and pharmacological agents such as ketamine and psilocybin [ 7 , 8 ] when gold standards such as CBT prevail. This year also saw the opening of the first Australian residential centre for people with eating disorders which has embraced the concept of therapists with lived experience providing care [ 9 ]. Other areas are innovating. Those in our field who care for people with binge eating spectrum and comorbid metabolic disorders will be aware of the rapid rise of new glucagon-like peptide-1 receptor agonists used in combination with increasingly sophisticated behavioural weight loss therapies to treat type 2 diabetes. We cannot rest on our laurels.

Just published in the Journal of Eating Disorders , Levinson et al. [ 10 ] report on a proof of concept study and initial data in using networks to identify treatment targets for eating disorder treatment. They are adopting individualised network analyses utilising comprehensive longitudinal data via ecological momentary assessment to “model how dynamic systems of symptoms interrelate with each other to maintain pathology, within one person”. We need to truly embrace personalised care models for recovery and to learn what works for whom and when. It is no longer good enough to present data on attrition with the concept that people needed to stay with treatment and all would be well. Rather than people failing treatment, there is an imperative to refine the treatment to meet the person and their family’s needs. As enunciated by Gustafsson et al . [ 11 ] it is incumbent on us to increase our understanding of the treatment experience and to learn with those experiencing an eating disorder how to refine approaches and therapies.

We urgently need paradigm shifts to do for our field what has been done in developing vaccines and treatments for Covid-19. To mark the 10th year of the Journal of Eating Disorders, a series of special themed issues are planned. These include collections on medical assessment and management, environmental influences on eating disorders, disordered eating and body image, a trans-diagnostic understanding of binge eating, and a series of rapid reviews and updates for the field. It is hoped that the papers published in these as well as invited commentaries and editorials will be part of a global transformation of research to ultimately deliver more effective outcomes for people living with eating disorders. The researchers are here, as well as organisations such as the Academy of Eating Disorders and the Eating Disorders Research Society, other high calibre clinical/research bodies in many counties such as ANZAED (see the recent conference proceedings [ 12 ]) and a plethora of regular international and national conferences to rapidly disseminate research findings. If there was ever a time to feel optimistic about our field it is now.

Availability of data and materials

Not applicable.

Abbreviations

Anorexia Nervosa

Australian and New Zealand Academy for Eating Disorders

Cognitive Behaviour Therapy

Coronavirus disease

Family Based Treatment

McLean C, Utpala R, Sharp G. The impacts of COVID-19 on eating disorders and disordered eating: A mixed studies systematic review and implications for healthcare professionals, carers, and self. Preprint. file://ad.uws.edu.au/dfshare/HomesCMB$/30021271/Downloads/McLean,%20Utpala,%20and%20Sharp,%202021.pdf. Accessed 28 Dec 2021.

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Patient handouts, what are eating disorders.

Eating disorders are serious mental health disorders. They involve severe problems with your thoughts about food and your eating behaviors. You may eat much less or much more than you need.

Eating disorders are medical conditions; they are not a lifestyle choice. They affect your body's ability to get proper nutrition. This can lead to health issues, such as heart and kidney problems, or sometimes even death. But there are treatments that can help.

What are the types of eating disorders?

Common types of eating disorders include:

• Binge-eating , which is out-of-control eating. People with binge-eating disorder keep eating even after they are full. They often eat until they feel very uncomfortable. Afterward, they usually have feelings of guilt, shame, and distress. Eating too much too often can lead to weight gain and obesity . Binge-eating disorder is the most common eating disorder in the U.S.
• Bulimia nervosa. People with bulimia nervosa also have periods of binge-eating. But afterwards, they purge, by making themselves throw up or using laxatives. They may also over-exercise or fast. People with bulimia nervosa may be slightly underweight, normal weight, or overweight.
• Anorexia nervosa. People with anorexia nervosa avoid food, severely restrict food, or eat very small quantities of only certain foods. They may see themselves as overweight, even when they are dangerously underweight. Anorexia nervosa is the least common of the three eating disorders, but it is often the most serious. It has the highest death rate of any mental disorder.

What causes eating disorders?

The exact cause of eating disorders is unknown. Researchers believe that eating disorders are caused by a complex interaction of factors. These include genetic, biological, behavioral, psychological, and social factors.

Who is at risk for eating disorders?

Anyone can develop an eating disorder, but they are more common in women. Eating disorders frequently appear during the teen years or young adulthood. But people can also develop them during childhood or later in life.

What are the symptoms of eating disorders?

The symptoms of eating disorders vary, depending on the disorder:

The symptoms of binge-eating include:

• 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

The symptoms of bulimia nervosa include the same symptoms as binge-eating, plus trying to get rid of the food or weight after binging by:

• Purging, making yourself throw up or using laxatives or enemas to speed up the movement of food through your body
• Doing intensive and excessive exercise

Over time, bulimia nervosa can cause health problems such as:

• Chronically inflamed and sore throat
• Swollen salivary glands in the neck and jaw area
• Worn tooth enamel and increasingly sensitive and decaying teeth . This is caused by the exposure to stomach acid every time you throw up.
• GERD (acid reflux) and other gastrointestinal problems
• Severe dehydration from purging
• Electrolyte imbalance , which could be too low or too high levels of sodium, calcium, potassium and other minerals. This can lead to a stroke or heart attack .

The symptoms of anorexia nervosa include:

• Eating very little, to the point of starving yourself
• Intensive and excessive exercise
• Extreme thinness
• Intense fear of gaining weight
• Distorted body image - seeing yourself as overweight even when you are severely underweight

Over time, anorexia nervosa can cause health problems such as:

• Thinning of the bones (osteopenia or osteoporosis )
• Mild anemia
• Muscle wasting and weakness
• Thin, brittle hair and nails
• Dry, blotchy, or yellowish skin
• Growth of fine hair all over the body
• Severe constipation
• Low blood pressure
• Slowed breathing and pulse
• Feeling cold all the time because of a drop in internal body temperature
• Feeling faint, dizzy , or weak
• Feeling tired all the time
• Infertility
• Damage to the structure and function of the heart
• Brain damage
• Multiorgan failure

Anorexia nervosa can be fatal. Some people with this disorder die of complications from starvation, and others die of suicide .

Some people with eating disorders may also have other mental disorders (such as depression or anxiety ) or problems with substance use .

How is eating disorders diagnosed?

Because eating disorders can be so serious, it is important to seek help if you or a loved one thinks that you might have a problem. Your health care provider may use many tools to make a diagnosis:

• A medical history, which includes asking about your symptoms. It is important to be honest about your eating and exercise behaviors so your provider can help you.
• A physical exam
• Blood or urine tests to rule out other possible causes of your symptoms
• Other tests to see whether you have any other health problems caused by the eating disorder. These can include kidney function tests and an electrocardiogram (EKG or ECG).

What are the treatments for eating disorders?

Treatment plans for eating disorders are tailored to individual needs. You will likely have a team of providers helping you, including doctors, nutritionists, nurses, and therapists. The treatments may include:

• Individual, group, and/or family psychotherapy. Individual therapy may include cognitive behavioral approaches, which help you to identify and change negative and unhelpful thoughts. It also helps you build coping skills and change behavioral patterns.
• Medical care and monitoring, including care for the complications that eating disorders can cause
• Nutrition counseling. Doctors, nurses, and counselors will help you eat healthy to reach and maintain a healthy weight.
• Medicines, such as antidepressants , antipsychotics, or mood stabilizers, may help treat some eating disorders. The medicines can also help with the depression and anxiety symptoms that often go along with eating disorders.

Some people with serious eating disorders may need to be in a hospital or in a residential treatment program. Residential treatment programs combine housing and treatment services.

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• Anorexia Nervosa (Department of Health and Human Services, Office on Women's Health) Also in Spanish
• Avoidant/Restrictive Food Intake Disorder (Merck & Co., Inc.) Also in Spanish
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Journal Articles References and abstracts from MEDLINE/PubMed (National Library of Medicine)

• Article: Symptoms of Depression, Eating Disorders, and Binge Eating in Adolescents With...
• Article: Predictors of the sustainability for an evidence-based eating disorder prevention program...
• Article: The impact of oxytocin on emotion recognition and trust: Does disordered...
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• National Eating Disorders Association
• Anorexia and Bulimia: How Eating Disorders Can Affect Your Child (American Academy of Pediatrics) Also in Spanish
• Avoidant/Restrictive Food Intake Disorder (ARFID) (For Parents) (Nemours Foundation)
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Eating Disorders: An Overview of Indian Research

Sivapriya vaidyanathan, pooja patnaik kuppili, vikas menon.

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Address for correspondence: Dr. Pooja Patnaik Kuppili Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan - 342 005, India. E-mail: [email protected]

Received 2018 Nov 9; Accepted 2019 Jan 18.

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

There has been sporadic research on eating disorders in India, with no published attempt to collate and summarize the literature landscape. Hence, the present narrative review aims to summarize Indian work related to eating disorders, discern current trends, and highlight gaps in research that will provide directions for future work in the area. Electronic search using the MEDLINE, Google Scholar, and PsycINFO databases was done to identify relevant peer-reviewed English language articles, in October 2018, using combinations of the following medical subject headings or free text terms: “eating disorders,” “anorexia nervosa,” “bulimia,” “treatment,” “epidemiology,” “co-morbidity,” “management,” “medications,” “behavioral intervention,” and “psychosocial intervention.” The data extracted from studies included details such as author names, year, from which of the states in India the work originated, type of intervention (for interventional studies), comparator (if any), and major outcomes. There is increasing research focused on eating disorders from India over the last decade, but it continues to be an under-researched area as evidenced by the relative paucity of original research. The cultural differences between east and west have contributed to variations in the presentation as well as challenges in the diagnosis. Hence, there is a need for the development of culturally sensitive instruments for diagnosis, as well as generating locally relevant epidemiological data about eating disorders from community and hospital settings.

Keywords: Anorexia nervosa , bulimia nervosa , eating disorder , India

The earliest description of an eating disorder (ED)-like syndrome appears in a treatise by Morton (1694), under the section “Nervous Consumption,” where the author talks about two adolescents who presented with loss of appetite, extreme fasting, weight loss, and their treatment and outcome.[ 1 ] Historical reports point to the existence of ED even in the 17 th century, referred to as “holy anorexia.” However, one of the first scientific reports of this condition, in the late 19 th century, was by William Gull who is credited with coining the term anorexia nervosa (AN).[ 2 ] In India, the occurrence of ED was not reported until the late 20 th century.[ 3 ] Perhaps, media-related glorification of “size zero” body type and culturally sanctioned drive for thinness, body shaming, and dissatisfaction have contributed to the recent upsurge of ED cases.[ 4 , 5 , 6 ] Traditionally, these parameters have been less of a concern in India than other countries.[ 4 ] Yet, another reason for the recent increase in the incidence of ED such as bulimia nervosa (BN) and binge eating disorder (BED) is more easy access to media outlets promoting unhealthy body types and higher socioeconomic status of people.[ 7 , 8 ]

Notwithstanding its increasing prevalence rates, ED continues to be an area that is under-reported and under-researched. There are several reasons why ED must be given increasing focus in health care research and policy planning in today's scenario. AN, a prototype ED, has the highest mortality rate among mental health disorders.[ 9 , 10 ] The economic and social impact of ED was estimated to be upwards of $15 billion (INR 1057.8 billion) in 2012, which is comparable to the productivity impact of anxiety and depression, estimated at $17.9 billion (INR 1262.3 billion) in 2010.[ 9 ] Though, relatively rare in the general population, the individual impact of ED can be quite debilitating and long-term treatments are often expensive. ED have high rates of psychiatric and medical co-morbidity.[ 9 , 10 , 11 , 12 ]

Though there has been sporadic research on ED in India, there has been no attempt to collate and summarize the literature landscape. We undertook the present narrative review with the objectives of summarizing Indian work related to ED, discern current trends, and highlight gaps in research that will provide directions for future work in the area. These would potentially answer key questions on the clinical presentation and trajectories of ED in our setting.

METHODOLOGY

Search strategy and study selection.

Electronic search using the MEDLINE, Google Scholar, and PsycINFO to identify relevant peer-reviewed English language articles was carried out to include articles between April 1967 to October 2018. We used random combinations of the following medical subject headings or free text terms: “eating disorders,” “anorexia nervosa,” “bulimia,” “treatment,” “epidemiology,” “co-morbidity,” “management,” “medications,” “behavioral intervention,” and “psychosocial intervention.”

This being a narrative review and because research on ED in India is relatively sparse, we included all types of research reports, including case reports, to gain a true picture of the research landscape. The initial search yielded 84 articles. From the initial search, 39 articles were relevant and therefore selected for inclusion in the review. The full text of these articles was retrieved electronically. Additionally, the reference section of all articles was manually screened to identify potentially relevant articles. We only selected articles describing research from India. There was no restriction on the date of publication. Citation indexing services and gray literature such as conference proceedings were not included in the present review.

Data extraction

The data extracted from studies included details such as author names, year, from which of the states in India the work originated, type of intervention (for interventional studies), comparator (if any), and major outcomes.

A major part of the literature on ED from India is derived from case reports and case series ( n = 24). In comparison, there are 15 original studies summarized in Table 1 .

Summary of original studies on eating disorders in India

AN – Anorexia nervosa; BDI – Beck’s Depression Inventory; BED – Binge eating disorder; BITE – Bulimia investigatory test; BSQ – Body shape questionnaire; BN – Bulimia nervosa; DSM-IV – Diagnostic and Statistical Manual of Mental Disorders Version IV; DSM-III – Diagnostic and Statistical Manual of Mental Disorders Version III; EAT – Eating attitudes test; EDS – Eating distress syndrome; ICD-10 – International Classification of Diseases; QOL EDs – Quality-of-life for eating disorders questionnaire; SCOFF – Sick, Control, One-stone (14 lbs/6.5 kg), Fat, Food; SRQ – Self-report questionnaire; SQ-EDS – Screening questionnaire for eating distress syndrome

The earliest reports of ED date back to 1966. The case was of AN in a 42-year-old female with episodes of compulsive fasting for 2 years. The patient was treated with 100 mg chlorpromazine, 100 ml of 25% glucose with vitamin C 500 mg intravenously, 10 injections of liver extract 2 ml intramuscularly biweekly, and 9 sessions of electroconvulsive treatment. After 46 days of intensive pharmacotherapy and supportive psychotherapy, she showed improvement and was kept in close follow up.[ 3 ] Following this, there has been increasing reports of ED cases in the last two decades. Majority of the cases were of AN, especially restrictive subtype. The typical profile of cases described from India is of adolescent females,[ 26 , 27 , 28 , 29 , 30 , 31 ] belonging to Hindu religion,[ 29 , 31 , 32 ] and coming from an upper- or middle-socioeconomic background[ 26 , 27 , 28 , 29 , 31 , 33 ] In contrast, there are only four cases of male AN reported.[ 27 , 34 ] There is a single case report of AN described in a pair of monozygotic twins too.[ 35 ]

Cases of AN have been described in Indian adolescents belonging to Sikh religions, living in the United Kingdom.[ 34 ] The symptoms of AN were found to flare up after being teased by peers about weight which was followed by concerns about weight gain, in the majority of cases.[ 27 , 29 ] There is also a case of AN which had atypical features such as denial of fears of weight gain.[ 36 ] One report of disordered eating described a young female, in whom “not eating” was conceptualized as a resistance to the patriarchal system and this highlights the role of Indian sociocultural factors for developing an ED.[ 37 ]

Bradycardia, hypotension, anemia, and dyselectrolytemia have been reported at the time of presentation to a psychiatrist.[ 27 , 28 , 38 ] Wernicke–Korsakoff syndrome was the presenting symptom for a 39-year-old female who had AN from adolescence.[ 39 ] Surreptitious use of metformin, with episodes of hypoglycemia, was the presenting symptom in another case of AN in a 21-year-old female.[ 33 ] Though the nature of psychiatric co-morbidity has not been described, psychiatric co-morbidity was noted in all the cases of a case series.[ 27 ] Obsessive traits of symmetry and order,[ 32 ] obsessive compulsive disorder (OCD),[ 40 ] and major depressive disorder have been reported as co-morbidities.[ 33 ] Menstrual abnormalities and poorly developed secondary sexual characteristics have been noted in the majority of cases.[ 26 , 27 , 28 , 32 , 41 ]

There have been only five cases of BN reported till date.[ 42 , 43 , 44 , 45 , 46 ] Two of the cases were females: one was a 22-year-old medical student, with the onset of symptoms around 13 years of age, with binging and purging with isabgol husk and consumption of orlistat.[ 44 , 45 ] The other three cases were atypical, with an absence of concerns for body weight or body image, along with an absence of concurrent use of diuretics or laxatives in a 37-year-old male,[ 46 ] 15-year-old female,[ 43 ] and a 24-year-old female.[ 42 ]

Cases of ED have been described occurring co-morbid to physical illnesses such as systemic lupus erythematosus[ 26 ] and secondary to traumatic brain injury[ 31 ] or due to an adverse drug reaction to zolpidem consumption termed as a nocturnal sleep-related ED.[ 47 ] Further, AN has been found to mask physical illnesses such as carcinoma.[ 48 ] Treatment described in these cases included comprehensive treatment involving mental health professionals and dieticians.[ 26 , 27 ]

Majority of cases were managed in the in-patient setting.[ 3 , 26 , 27 ] In AN, high-calorie high-protein diet has been advised, with careful monitoring for re-feeding syndrome.[ 26 , 27 ] In the 1960s, chlorpromazine and modified insulin therapy were the treatment options used.[ 3 ] Cyproheptadine in combination with chlorpromazine,[ 26 ] combination of cyproheptadine and olanzapine,[ 41 ] mirtazapine,[ 27 ] risperidone,[ 27 ] trazodone,[ 27 ] citalopram,[ 27 ] and fluoxetine at 20 mg/day[ 28 ] have been used for treatment of AN. Combinations of olanzapine and fluvoxamine or olanzapine and fluoxetine have been used in cases of AN with obsessive traits and OCD, respectively.[ 32 , 40 ] Sertraline[ 42 ] and fluoxetine at low dose of 20 mg/day[ 44 ] as well as at 80 mg/day[ 42 ] has been described in the management of BN, with good response.

The non-pharmacological therapy of ED included family therapy, cognitive behavioral therapy (CBT), supportive psychotherapy, contingency management, hypnotherapy, and play therapy.[ 26 , 27 , 29 , 31 , 42 , 43 , 44 , 49 ] High-frequency repetitive transcranial magnetic stimulation (rTMS) over the left dorsolateral prefrontal cortex was given as augmentation strategy in a 23-year-old female who earlier had only a partial response to antidepressants as well as atypical antipsychotics and CBT. rTMS was found to improve attitude toward body weight and body shape, with an improvement of weight.[ 38 ]

This review attempted to summarize the Indian research on ED. The literature is largely comprised of case reports, as noted in the previous reviews.[ 50 , 51 ] However, there has been an increase in the number of published original research articles over the last 5–6 years. There are no studies available which determined the prevalence of ED from the community setting. There is a single hospital-based retrospective review, which reported a prevalence of 1.25% for ED.[ 16 ] Of them, almost 85% had psychogenic vomiting and about 15% had AN. This is in contrast to the international literature, wherein the frequency of occurrence of BN and BED is more common than that of AN. A meta-analysis of 15 studies from various settings reported that the estimated lifetime prevalence of any ED was 1.01%, and those of AN, BN, and BED were 0.21%, 0.81%, and 2.22%, respectively.[ 52 ] BED had the highest point prevalence of ED, followed by BN and AN, among young females across China, Japan, Africa, and Latin America.[ 53 ] In comparison, in the Indian setting, there are no cases reported of BED, and only five cases have been reported of BN.[ 42 , 43 , 44 , 45 , 46 ] Further, the two-step assessment (initial screening by self-rated questionnaire, followed by assessment by semi-structured or diagnostic interview) is the standard procedure followed globally. However, there is a single study using the two-step procedure and found no cases.[ 14 ] Majority of the Indian studies used only the screening, self-rated assessment. The frequency of disordered eating/probable ED ranged from 4 to 45.4%.[ 18 , 25 ]

It is possible that subsyndromal ED cases may not be captured by a self-rated assessment. Two studies reported the prevalence of eating distress syndrome (EDS) to be 11% and 14.8%.[ 14 , 15 ] EDS refers to subsyndromal forms of AN or BN, with patients having distressing and conflicting thoughts about body shape and eating habits. EDS is characterized by strict dieting, and bingeing in a few cases, with no significant weight loss or behaviors such as resorting to severe measures of weight loss such as diet pills, starvation, purging, or vomiting.[ 14 ] However, there has been practically no Indian research on EDS in the last 20 years.

There are several methodological issues in Indian studies which need to be addressed. Firstly, many of the studies have employed convenient sampling on medical and nursing students.[ 14 , 15 , 18 , 22 , 24 , 25 ] This may lead to selection bias and such samples may not be truly representative of the population at large. However, this practice of studying medical students is popular worldwide. The rationale given to support this being the “stressful” nature of medical training, which could be a risk factor for ED.[ 54 , 55 , 56 ] But this may also imply that the prevalence rates obtained in these studies may be an inflated figure.

Secondly, in the measurement of the frequency of disordered eating, it was found to be higher as per the Sick, Control, One-stone, Fat, Food questionnaire (SCOFF) compared to the Eating Attitudes Test-26 item (EAT-26) questionnaire.[ 23 , 25 ] The frequency with SCOFF ranged from 17.2% in women to 45.4% in men, and the frequency with EAT-26 ranged from 4% to 31%.[ 6 , 18 , 24 , 25 ] Thirdly, there are limitations in the translation and implementation of the questionnaires in a setting like India that has such linguistic diversity. Though the EAT-26 questionnaire has been translated into Hindi, the cut-off score for the Hindi version has not been defined.[ 24 ] Also, the rationale for using the same cut-off of the English version in the Kannada version is not clear.[ 6 ] Hence, due to cultural differences between the western and Indian settings, there is a definite need for the development of culturally sensitive scales for screening ED.

Culture bears a strong influence on the presentation of ED in India. One unique point noted in the Indian presentations of ED is relative lack of concern for body fat/shape. This has been termed as “Non-fat phobic” variant of AN.[ 50 ] This has been described in Hong Kong as well. In this form, food restriction is attributed to somatic complaints such as abdominal bloating, pain, and lack of appetite, rather than concern for body fat. Similar atypical features have been noted in cases of BN too from India. Also, the concept of EDS is in accordance with this concept.[ 50 , 57 ] Further, food restriction is culturally sanctioned in Indian culture when one is unwell, for “cleansing the bowel.”[ 36 ] However, several recent studies show an association between perception of body shape and higher scores on EAT-26.[ 18 , 22 , 24 ] This could be explained by the ongoing rapid societal transitions in India and the increasing influence of western ideals.

At least 50% of patients with an ED are known to have a psychiatric co-morbidity, with depression being the most common.[ 58 , 59 ] In contrast, a few cases had syndromal co-morbidity.[ 27 , 40 ] The principles of management of ED adopted in India is similar to the west. Most reports of AN and BN describe using a combination of pharmacotherapy and psychotherapy. Selective serotonin reuptake inhibitors (SSRIs), second-generation antipsychotics, and cyproheptadine have been found to be effective for AN.[ 60 ] Patients with BN were treated with 20–80 mg/day of fluoxetine in the case reports.[ 42 , 44 ] In contrast, globally, a higher dose of SSRIs, especially fluoxetine, has been found to be effective in cases of BN.[ 61 ] Psychotherapeutic approaches used in the Indian setting, such as family-based therapy and CBT, therapy match global practices.[ 62 ]

To conclude, there is increasing research focus on ED from India over the last two decades. Lower prevalence of ED could be the reason for the relative paucity of studies. But, with the increasing impact of westernization of society, ED merit renewed focus. The cultural differences between east and west have contributed to variations in presentation as well as challenges in diagnosis. Hence, there is a need for the development of culturally sensitive instruments for diagnosis as well as generating locally relevant epidemiological data about ED from the community and hospital settings.

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