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Anorexia nervosa is often portrayed as an illness that has existed for centuries, does not respond well to treatment, and is surrounded by confusing and competing theories. Many people are told that little has changed despite decades of research and clinical work. This message appears in academic writing, the media, and everyday conversations. Over time, it shapes how professionals approach care, how families understand the illness, and how people with anorexia nervosa view their chances of recovery.
A recent article, Anorexia Nervosa: 150 Years of Critical Theory, reflects this way of thinking. Written by international experts, the paper reviews how anorexia nervosa has been understood over the past 150 years. It questions whether today’s theories and treatments truly work and suggests that the field may be stuck. The article is thoughtful and wide-ranging. However, it also raises an important concern: when criticism becomes too far removed from real-world care, it can overlook what is actually helping people with anorexia nervosa today.
One of the article’s strengths is its focus on history. 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 also examines modern treatments, especially Family-Based Treatment (FBT) and Enhanced Cognitive Behaviour Therapy (CBT-E). The authors point out that recovery rates are often modest and that many people leave treatment early. Importantly, they do not blame individuals with anorexia nervosa or their families for these outcomes. Instead, they suggest that the limits may lie in the theories behind the treatments. This matters because people with anorexia nervosa are too often described as “resistant” or “unmotivated” when treatment does not work.
Alongside these strengths, the article also leaves some important questions open. One issue is how it treats different theories. By focusing mainly on history and ideas, the paper tends to treat many explanations as equally flawed. This can blur meaningful differences. Some theories are supported by more evidence than others. Some have led to treatments that help a large number of people with anorexia nervosa. When everything is treated as equally uncertain, it becomes harder to judge what is useful in real clinical practice.
The article also calls for a more integrated understanding of anorexia nervosa, one that includes biology, psychology, relationships, and culture. This goal makes sense, and many clinicians already agree with it. However, the paper offers little guidance on how such integration would change treatment in practice. Without clear direction, integration risks remain an idea rather than a path forward.
One concern relates to how the article characterizes the current treatment landscape. The discussion may give the impression that few effective options exist. However, the paper gives limited attention to real-world structured outpatient services and intensive treatments such as day programs, residential and inpatient care, including intensive forms of CBT-E. While these approaches are not universally effective and recovery from anorexia nervosa is often gradual and non-linear, they have supported meaningful improvement for many individuals, including adolescents, those with more severe illness, and people who have lived with anorexia nervosa for extended periods.
Leaving these treatments out strengthens the belief that “nothing works,” when the reality is more complex. Some treatments help some people, some of the time. That may sound modest, but for a serious and life-threatening illness, it matters greatly. Medical stability, improved eating, or reduced risk can save lives.
This creates a tension in the article. The authors rightly point out the gap between theory and real-world care. Yet they avoid engaging with the uncomfortable fact that some treatments show benefits even without a clear or unified theory behind them. Instead of asking why partial success occurs, failure is treated as proof that entirely new theories are needed.
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The risk is that complexity becomes an excuse for inaction. If all models are flawed, then no one is responsible for outcomes. But people with anorexia nervosa do not live in theories. They live in clinics, hospitals, treatment programs, and families. For them, imperfect progress is not meaningless—it can be life-saving.
It’s an important and challenging article. It helps explain why the field often feels divided and why simple answers have failed. But criticism alone is not enough. If we want to improve care for anorexia nervosa, theory must remain connected to what happens in real lives.
The question the field can no longer avoid is simple: are we willing to take real-world improvement seriously, even when it does not fit neatly into our theories? Until we do, discussions about anorexia nervosa risk remaining thoughtful but disconnected from the people who most need help.
