Riccardo Dalle Grave
In recent years, an increasingly pessimistic narrative has taken hold around anorexia nervosa, portraying it as an ancient, treatment-resistant disorder marked by theoretical fragmentation and largely impervious to intervention. The article Anorexia Nervosa: 150 Years of Critical Theory by Bryant and colleagues fits squarely within this climate, offering a broad and sophisticated reconstruction of the disorder’s conceptual history while bringing into sharp relief the limitations of the theoretical models that have emerged over time.
This commentary arises from a dual imperative: first, to acknowledge and build upon the historical reconstruction advanced by Bryant et al.; and second, to critically examine what remains at the margins of their analysis—particularly interventions that, while imperfect, are demonstrating promising outcomes even among adolescents, in severe presentations, and in long-standing forms of the disorder. The aim is not to defend any single model, but to ensure that theoretical critique does not eclipse what is, in practice, proving effective.
One of the article’s principal strengths lies in its historical breadth. The authors trace self-starvation from ancient religious asceticism through Victorian hysteria, psychoanalytic formulations, cognitive-behavioural models, feminist critiques, evolutionary accounts, and contemporary biopsychosocial and metabo-psychiatric theories. This reconstruction makes a significant contribution by demonstrating that anorexia nervosa has never been understood through a linear or cumulative explanatory framework, but rather through paradigms that are often in competition and deeply shaped by broader epistemological, cultural, and ideological shifts. In doing so, it exposes the extent to which prevailing models are shaped as much by historical context as by empirical discovery.
The article is also notable for its critical stance toward contemporary treatment paradigms. Bryant et al. highlight modest recovery rates, high dropout, and limited long-term efficacy associated with dominant psychological interventions, particularly Family-Based Treatment (FBT) and CBT-E. Importantly, these limitations are framed not as failures of implementation or patient compliance, but as symptoms of deeper theoretical incoherence. This reframing resists the tendency within clinical discourse to attribute poor outcomes to illness severity or individual resistance, redirecting attention instead to the conceptual foundations upon which treatments are built.
The inclusion of a reflexivity statement further strengthens the paper’s critical credentials. By explicitly acknowledging the authors’ professional, cultural, and experiential positioning—including lived experience of anorexia nervosa—the paper aligns itself with epistemologically reflexive traditions that challenge claims to theoretical neutrality. This transparency is consistent with the article’s broader argument that knowledge production in psychiatry is inevitably shaped by the positionality of its producers.
Despite these strengths, the paper also reveals several limitations that constrain its capacity to move the field forward. Some of these risk reproducing the very fragmentation the authors seek to diagnose.
First, the narrative methodology, while appropriate for historical synthesis, introduces interpretive vulnerabilities. The selection of sources based on “conceptual relevance” rather than systematic criteria allows for both breadth and depth but limits reproducibility and weakens claims regarding the relative failure of contemporary models. Theories with markedly different empirical foundations are treated as equally contingent historical artefacts, producing a flattening effect that obscures meaningful distinctions in explanatory power and clinical utility. Fragmentation is meticulously described, yet the absence of evaluative criteria leaves the reader uncertain as to how theoretical adequacy should be assessed moving forward.
Second, although the article repeatedly calls for a “new integration,” this proposal remains largely aspirational. The need for a multidimensional framework incorporating biological, psychological, relational, and cultural dimensions is convincingly articulated, but little guidance is offered on how such integration might be operationalised. The mechanisms through which different levels of explanation might interact—without reverting to biological reductionism on the one hand or sociocultural determinism on the other—remain unspecified. As a result, integration is positioned as an epistemic ideal rather than as a concrete research or clinical agenda.
A further limitation concerns the article’s implicit epistemological positioning. Despite its reflexive gesture, the paper remains firmly anchored within an academic perspective. The experiential knowledge of clinicians working in frontline services and of individuals with lived experience of long-term treatment trajectories is acknowledged conceptually but not integrated as an autonomous source of theoretical insight. This omission is notable, given that some of the most grounded critiques of dominant models originate precisely in these settings, where the limits of theory are encountered daily in clinical practice.
This tension becomes particularly salient in the article’s selective engagement with contemporary clinical evidence, which conveys an unduly bleak picture of the current clinical landscape and overlooks recent developments that merit closer scholarly attention. For example, the absence of any substantive discussion of intensive real-world treatments—such as intensive outpatient, day-hospital, or inpatient rehabilitation programmes, including intensive CBT-E—cannot be dismissed as incidental. These interventions are neither marginal nor residual remnants of the 1990s. Rather, they represent some of the few treatment modalities that have demonstrated relatively consistent outcomes in severe presentations, adolescent populations, and long-standing illness outside idealised experimental conditions. Their omission reinforces a narrative of generalised therapeutic failure that fails to distinguish between what has demonstrably not worked and what—despite significant limitations—has shown effectiveness for a substantial minority of individuals.
If the stated aim of Anorexia Nervosa: 150 Years of Critical Theory is to stimulate a new phase of reflection and innovation, this omission constitutes a significant internal contradiction. A call for radical rethinking cannot proceed while avoiding engagement with the limited but meaningful evidence that something in the current clinical landscape is working. A critique that fails to distinguish between theoretical inadequacy and clinical progress risks producing paralysis rather than transformation.
A deeper problem is embedded in this stance. On the one hand, the article rightly denounces the distance between theory and clinical reality; on the other, it avoids sustained engagement with the most uncomfortable evidence—namely, that certain interventions yield outcomes that complicate a narrative of pervasive failure. The critique looks backward with considerable clarity, yet approaches the present through a lens that treats failure as confirmation of the need for new theories, rather than asking why some treatments appear to work despite the absence of a unified theoretical model.
The risk is that complexity becomes an alibi. If all models are fragmented and none is adequate, then none is required to account for its outcomes. Such a position may be epistemologically elegant, but it is clinically sterile. Individuals with anorexia nervosa do not inhabit theoretical paradigms; they inhabit services, treatment pathways, inpatient units, and intensive programmes. Some of these, at present, produce outcomes that are better than the article allows.
In sum, Anorexia Nervosa: 150 Years of Critical Theory is an important and thought-provoking contribution. It offers a compelling account of why the field is in difficulty, but provides less clarity on how it might move forward. Most critically, it avoids confronting a question that can no longer be deferred: are we willing to subject our critiques to the discipline of real-world data, or do we prefer a state of permanent theoretical crisis that absolves us from recognising what works when it does not align neatly with our conceptual preferences?
Until this question is addressed, there remains a risk that critical scholarship on anorexia nervosa will remain intellectually sophisticated yet clinically distant from the realities faced by those who continue to bear the greatest burden of the disorder.
Reference
Bryant E, Touyz S, Oldershaw A, Treasure J, Maguire S. Anorexia nervosa: 150 years of critical theory. J Eat Disord. 2026. doi: 10.1186/s40337-026-01528-7.