The research, led by Lucy Hyam of King’s College London with colleagues including Karina L Allen and Ulrike Schmidt, was grounded in a critical realist perspective, a philosophical stance that treats participants’ accounts as windows onto real underlying causal mechanisms rather than as mere opinion. Between interviews and focus groups, the team gathered data from 21 participants: ten people with lived experience of an eating disorder, two carers and nine clinicians. The material was analysed using Fryer’s critical realist approach to thematic analysis, in which themes are developed not simply as descriptive labels but as nuanced causal explanations of how participants understood illness development, progression, treatment and recovery. This is a methodologically demanding form of qualitative analysis, seeking to model the mechanisms that drive phenomena rather than only cataloguing what was said.

Five superordinate themes emerged from the analysis. The first concerned clinical staging itself, framed by the authors as seeking structure in a fluid illness. The second captured how eating disorders take hold and hold on, a phrase that conveys the process by which restrictive, bingeing or compensatory behaviours consolidate from early, seemingly controllable habits into entrenched patterns that feel inseparable from a person’s identity. The third theme addressed the wider forces shaping illness trajectories, including social, relational and systemic influences. The fourth examined how healthcare experiences themselves influence illness progression, an unexpected but clinically significant finding, and the fifth focused on recovery as building life beyond the eating disorder, a conception of recovery that extends beyond symptom remission toward restored social and personal functioning.

On the central question of validity, the study found broad support: staging, participants suggested, could largely be interpreted as an accurate framework for conceptualising eating disorders. Many recognised the value of a model that communicates where someone sits along the course of illness and what might be expected next. Yet this endorsement came with a consistent and important caveat. Across all three participant groups, eating disorders were described as following a non-linear trajectory. People described periods of improvement followed by relapse, shifts between different patterns of disordered eating, and partial recoveries that did not follow a neat progression from mild to severe. Participants worried that staging systems, if applied rigidly, could impose an artificial order on a fundamentally fluctuating illness, potentially locking patients into a fixed clinical narrative.

This tension between structure and fluidity goes to the heart of why staging in psychiatry is contested. In oncology, staging is anchored in measurable anatomy, such as tumour size and spread, and a stage once assigned rarely reverses. In eating disorders, the proposed anchors are behavioural and psychological, including the duration and severity of restriction or bingeing, physical complications, and the degree to which the illness dominates identity and daily life. The present study identified candidate stage-defining features that resonate with this, with participants pointing to changes in habits, identity and physical health, and shifts in symptoms over time. Such markers align with the general thrust of emerging staging models in eating disorders, which typically distinguish an early or at-risk phase, in which behaviours are intermittent and self-esteem remains tied to sources outside the illness, from later stages in which behaviours become habitual, medically dangerous and central to a person’s sense of self.

The causal emphasis of the critical realist analysis produced one of the study’s most consequential findings: illness progression was felt to be strongly influenced by gaps in treatment and delays in accessing care. Participants identified multiple barriers to early intervention in eating disorders, a familiar problem given the well-documented pattern of long delays between symptom onset and first contact with specialist services. If the course of illness can be reshaped by the health system itself, then stages are not purely properties of the disease but partly artefacts of service provision. This reframes staging from a descriptive exercise into something with real accountability attached: a delayed referral or a demoralising episode of care can, in effect, move a person from an early to a later stage.

That insight connects directly to the fourth theme, in which harmful treatment experiences were seen as shaping both illness progression and the stages people pass through. Participants suggested that negative encounters with healthcare, such as dismissive responses, rigid protocols or care experienced as shaming, could entrench the illness or deter help-seeking, whereas personalised and compassionate care was described as vital across all participant groups. Combined with the study’s conclusion that early intervention is crucial to prevent illness progression, this implies that any staging system for eating disorders must be paired with services capable of acting on it promptly and humanely. The authors’ related research environment, including programmes such as FREED, a service designed to deliver rapid early intervention for first-episode eating disorders, reflects precisely this ambition of closing the gap between onset and treatment.

The overall conclusion of the study is a preference for staging approaches that are flexible and person-centred, capable of accommodating individual differences, non-linear trajectories and what the authors call stage-modifying factors, meaning influences such as treatment access and healthcare experience that can accelerate, delay or reverse progression between stages. In staging terminology, modifiers act as caveats that adjust the interpretation of the primary stage; in eating disorders, participants’ accounts suggest these modifiers may be as consequential as the stage itself. This has practical implications for how any future staging model is built and implemented: it should be explicit that regression is possible, that transitions between diagnostic patterns are common, and that a person’s stage is a dynamic clinical summary rather than a permanent label.

For clinicians, the study offers a usable framework for conversations with patients about where they are in their illness and what might change that course, while the findings caution against letting a stage number eclipse the individual. For researchers, the study demonstrates the value of stakeholder input, drawing on those with lived experience, carers and clinicians, in informing the development and refinement of clinical staging models, a process that has often been driven by expert consensus alone. The authors argue that incorporating these perspectives may increase both the acceptability and the perceived validity of staging among the people it is ultimately designed to help. Given that eating disorders carry among the highest mortality and burden of any psychiatric condition, and that early intervention is repeatedly shown to improve prognosis, a staging model that survives contact with lived reality could help target scarce treatment resources where they matter most: at the earliest, most modifiable point in the illness.

The study, conducted at King’s College London with the South London and Maudsley NHS Foundation Trust, received ethical approval from the King’s College London Research Ethics Office and was published open access, reflecting growing recognition that the future of eating disorder care depends on models shaped jointly by science and by the people who live with the illness every day.

Subject of Research: Clinical staging frameworks for eating disorders explored through qualitative interviews with patients, carers and clinicians

Article Title: Clinical staging in eating disorders: qualitative insights from those with lived experience, carers, and clinicians

Article References: Hyam, L., Karabıçak, I., Elsheikh, A., Carnegie, A., Allen, K. L., & Schmidt, U. (2026). Clinical staging in eating disorders: qualitative insights from those with lived experience, carers, and clinicians. Journal of Eating Disorders. https://doi.org/10.1186/s40337-026-01775-8

Image Credits: AI Generated

DOI: 10.1186/s40337-026-01775-8

Keywords: eating disorders, clinical staging, qualitative research, anorexia nervosa, early intervention, recovery, mental health services, thematic analysis, carers, illness trajectory, person-centred care, Journal of Eating Disorders