Commentary Questions Anorexia Nervosa Diagnostic Shift

A new commentary published in the Journal of Eating Disorders critically examines the historical evolution of anorexia nervosa (AN) diagnostic criteria, arguing that the field has moved away from observable clinical signs toward unobservable psychological symptoms. The manuscript, authored by Emilio Gutiérrez, uses a historical thought experiment grounded in the perspective of William Gull, a physician who died in 1888, to contrast contemporary diagnostic standards with original clinical descriptions. The author posits that this conceptual shift has increased diagnostic heterogeneity, potentially complicating efforts to identify underlying biological mechanisms and develop effective treatments for the disorder.

Historically, anorexia nervosa was defined by observable signs that were relatively stable and uncommon among other psychiatric disorders. These included severe weight loss, food restriction, hyperactivity, and amenorrhea. The commentary notes that the disorder was also characterized by a predominant onset during adolescence and a markedly higher prevalence among females. In contrast, modern Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria have increasingly privileged unobservable psychological symptoms, particularly fear of weight gain and body image disturbance, while de-emphasizing or eliminating these earlier clinical signs.

This diagnostic shift culminated in the introduction of “atypical anorexia nervosa” (AAN) in DSM-5, which allows for a diagnosis of AN in individuals of normal or above-normal weight. The author argues that this development reflects a broader epistemic move from signs to symptoms, a transition largely driven by the widespread acceptance of Hilde Bruch’s psychopathological model. By prioritizing internal psychological states over external behavioral and physiological markers, the current diagnostic framework may obscure the biological realities of starvation and excessive activity that define the condition.

Evidence from non-Western populations and Western clinical samples suggests that fear of fatness and body image disturbance are not universal features of anorexia nervosa. Additionally, the author points to the marginalization of hyperactivity, an early and prevalent clinical sign, in both current diagnostic systems and research.

The manuscript further contends that progress in understanding the underlying psychopathological processes in anorexia nervosa has not been mirrored by improved clinical outcomes. The author suggests that the current focus on self-perception and body image may be a misdirected inquiry, proposing instead that research should direct greater attention to the starvation component of self-starvation. This reorientation would involve placing greater emphasis on the behavioral and physiological criteria of DSM-5, specifically the latter components of criteria B and C, which relate to behavioral phenotypes.

By leveraging DSM-5 alternative criteria that emphasize observable behavioral phenotypes, the author proposes a reorientation of AN diagnosis aimed at reducing diagnostic heterogeneity. This approach would enhance the translational validity of animal models, specifically the activity-based anorexia (ABA) paradigm. The ABA paradigm links starvation, thermoregulation, and excessive activity, providing a biological framework that is analogous to the human disorder. Research on ABA has been highly informative in guiding novel adjunctive approaches to the treatment of anorexia nervosa, such as strategies for reducing postprandial anxiety.

The commentary warns that successive diagnostic reformulations may inadvertently introduce additional noise into research approaches, including genome-wide association studies (GWAS). Such heterogeneity can obscure disorder-specific signals, yielding findings that reflect factors shared across a broad range of DSM-5 diagnoses rather than those unique to anorexia nervosa. This noise complicates the identification of underlying mechanisms, which is essential for developing more effective treatment strategies.

The author concludes by reflecting on the legacy of William Gull, suggesting that if he were to rise from his grave, he might question whether contemporary developments have clarified or further complicated the conceptualization of anorexia nervosa. The commentary advocates for a shift in focus from the self as the primary object of inquiry to the physiological consequences of starvation. By prioritizing observable behavioral phenotypes and integrating insights from animal models, the field may better understand the mechanisms underlying anorexia nervosa.

Subject of Research: Critical examination of anorexia nervosa diagnostic criteria evolution

Article Title: What if William Gull were to rise from the grave?

Article References: Gutiérrez, E. (2026). What if William Gull were to rise from the grave?. Journal of Eating Disorders, 14(1), Article 262. https://doi.org/10.1186/s40337-026-01818-0

Image Credits: AI Generated

DOI: 10.1186/s40337-026-01818-0

Keywords: anorexia nervosa, diagnostic criteria, DSM-5, William Gull, psychopathology, clinical signs, body image, hyperactivity, atypical anorexia, animal models, William, Gull