Current Psychiatry Reports (2018) 20: 79

https://doi.org/10.1007/s11920-018-0932-9

EATING DISORDERS (S WONDERLICH AND JM LAVENDER, SECTION EDITORS)

An Overview of Conceptualizations of Eating Disorder Recovery, Recent

Findings, and Future Directions
Anna M. Bardone-Cone 1 & Rowan A. Hunt 2 & Hunna J. Watson 3,4,5

Published online: 9 August 2018

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of Review This review delineates issues in the conceptualization and operationalization of eating disorder recovery,
highlights recent findings about recovery (since 2016), and proposes future directions.
Recent Findings A longstanding problem in the field is that there are almost as many different definitions of recovery in eating
disorders as there are studies on the topic. Yet, there has been a general shift to accepting that psychological/cognitive symptoms
are important to recovery in addition to physical and behavioral indices. Further, several operationalizations of recovery have
been proposed over the past two decades, and some efforts to validate operationalizations exist. However, this work has had
limited impact and uptake, such that the field is suffering from “broken record syndrome,” where calls are made for universal
definitions time and time again. It is critical that proposed operationalizations be compared empirically to help arrive at a
consensus definition and that institutional/organizational support help facilitate this. Themes in recent recovery research include
identifying predictors, examining biological/neuropsychological factors, and considering severe and enduring anorexia nervosa.
From qualitative research, those who have experienced eating disorders highlight recovery as a journey, as well as factors such as
hope, self-acceptance, and benefiting from support from others as integral to the process of recovery.
Summary The field urgently needs to implement a universal definition of recovery that is backed by evidence, that can parsi-
moniously be implemented in clinical practice, and that will lead to greater harmonization of scientific findings.

Keywords Eating disorders . Recovery . Course . Outcome . Remission . Transdiagnostic

Introduction is seen as the ideal end-goal, giving rise to a number of critical

questions including how recovery is defined and operational-
Every field of psychopathology cares about recovery. ized, what predicts recovery, and what interventions should
Regardless of the specific psychological disorder, recovery look like to best facilitate recovery. In this review, we provide
an overview of conceptualizations of recovery and then focus
This article is part of the Topical Collection on Eating Disorders on recent eating disorder recovery research (since 2016). We
will also occasionally refer to research on remission and
* Anna M. Bardone-Cone “good outcomes” when there is little work specifically on
bardonecone@unc.edu recovery. Of note, these various terms (recovery, remission,
good outcomes) represent overlapping but distinct constructs
1
Department of Psychology & Neuroscience, University of North which are sometimes used interchangeably; the need for a
Carolina at Chapel Hill, CB #3270 Davie Hall, Chapel consistent terminology for better communication is discussed
Hill, NC 27599, USA
as part of future directions.
2
Department of Psychology, Drexel University, Philadelphia, PA,
USA
3
Department of Psychiatry, University of North Carolina at Chapel
Hill, Chapel Hill, NC, USA Defining and Operationalizing Recovery
4
School of Psychology, Curtin University, Perth, Western Australia,
Australia Researchers have done an excellent job acquiring volumes of
5
School of Paediatrics and Child Health, The University of Western data on outcomes and course of illness, particularly for an-
Australia, Perth, Western Australia, Australia orexia nervosa (AN) and bulimia nervosa (BN), [1–3].
79 Page 2 of 18
However, they have failed miserably at defining outcome in a
consistent way, making it almost impossible to integrate this
vast body of literature. Depending on the source, it is virtually
impossible to achieve recovery, or exceptionally likely. In her
review, Berkman [1] found recovery rates of 8 to 88% for
studies reporting four or more years of follow-up of AN, and
recovery rates of 56 to 99% for studies following BN for at
least 1 year. In a review of 119 studies, Steinhausen [3] found
recovery rates for AN to be between 0 to 92% and in 79
studies of BN, between 5 to 73% [4]. Couturier and Lock
[5] demonstrated that the large variation in recovery rate is
due in part to the wide-ranging definitions of recovery.
Using the same sample of individuals, and applying different
commonly used definitions, they found that 57 to 94% of
patients were “recovered.” Without a standard definition of
recovery and measurement strategy, the field cannot: mean-
ingfully compare recovery rates across studies; make strong
claims about relative treatment effectiveness; identify reliable
predictors of recovery; and report meaningful relapse rates,
given that relapse is predicated on recovery.
How does the eating disorder field—pragmatically—go
about acquiring a standard definition of recovery? Efforts with
respect to psychiatric disorders have predominantly taken two
routes, differing in philosophy and methods. In the first, more
quantitative approach, criteria are proposed based on
established conventions, expert working groups, or critical
reviews of the literature, i.e., [6••, 7, 8••, 9–12]. Next, these
criteria are subjected to empirical validation to test their ro-
bustness [5, 6, 9, 13, 14]. One way to test for validity is to
compare a group meeting the proposed recovery criteria to a
group meeting criteria for an eating disorder as well as to a
group of non-eating disorder controls on constructs that are
related to disordered eating attitudes and behaviors, but using
measures not included in the operationalization of recovery.
For example, groups could be compared on measures of eat-
ing pathology, body image, thin-ideal internalization, and ob-
sessive cognitions related to food, eating, and weight/shape.
Evidence of validity of the operationalization of recovery
would emerge if the recovered group looked significantly bet-
ter than the group with eating disorders on the validation
criteria, but did not differ significantly from controls, suggest-
ing a return to “normative” levels of these constructs (i.e.,
[6••]). Another way to test for validity is to use a longitudinal
research design to compare recovery operationalizations on
subsequent relapse rates (i.e., [9]). In this case,
operationalizations with lower relapse rates over time would
be highlighted as particularly valid and meaningful
operationalizations of recovery.
The second approach to characterizing the concept of re-
covery uses primarily qualitative methodology [15]. This ap-
proach situates patients’ narratives of their experiences with
recovery as primary. Both approaches have value and can
bridge important gaps in the other. Criticisms of the first
Curr Psychiatry Rep (2018) 20: 79
approach are that medical professionals and researchers but
not patients define the meaning of recovery (although criteria
may reflect important constructs reported by patients) and that
health is seen predominantly in terms of the reduction of
symptoms rather than building wellness. Criticisms of the
qualitative approach are that findings can be difficult to
operationalize, and criteria are too broad and non-specific
(e.g., “personal growth” [15••]), leading to too high a bar for
recovery.
Which criteria/domains should be included in a recovery
definition, which measurements should be used, and what
thresholds and duration of time should be considered? [15••]
Answers to these questions should be informed by quantita-
tive and qualitative data.
Criteria Contemporary clinical literature suggests that recov-
ery from eating disorders should be measured in terms of
physical, behavioral, and psychological/cognitive criteria [5,
6••, 13, 16]. This is not the status quo for assessing outcome in
many medical settings, where physical and behavioral criteria
are central. This is also not yet widespread in the literature; for
example, from 2016 through March 2018, only a minority of
the publications on recovery explicitly included these three
dimensions in their definition of recovery (see Table 1). And
yet, there are strong arguments for the inclusion of a psycho-
logical dimension as part of a comprehensive definition of
recovery. Residual eating disorder cognitions (e.g., body im-
age disturbance) increase risk for relapse [72, 73]. Measuring
recovery using only physical and behavioral indices yields a
group heterogeneous on eating disorder thinking and thus
with systematically differential risk for relapse. Indeed, some
have argued that this identifies a “pseudo-recovery” state
where someone may seem recovered via visible indicators
(weight, behaviors), but still engage in the same eating disor-
dered thinking [74]. Further, excluding psychological criteria
from a definition of recovery does not fit patients’ subjective
reports of recovery where changes in thinking are key [15••].
Measurement and Thresholds For the physical criterion of
recovery, body mass index (BMI) is the most commonly used
indicator. However, minimum thresholds are variable. Since
2016, BMI thresholds for recovery have included 17.5 [24,
47], 18 [49, 75], 18.5 [20, 59, 76•], and 19 [60, 77]. Of these
thresholds, a minimum BMI of 18.5 has been most often used
in recent years and has the backing of being the minimum
BMI for a normal/healthy weight range, per the World
Health Organization and the Centers for Disease Control and
Prevention. Weight and height measurements have been self-
reported and measured, with objective measures preferred due
to the potential for bias or, for those who do not weigh them-
selves, guessing. Historically, regular menses has also been
used as an indicator of recovery, for example, paired with ≥
85% ideal body weight for a “good” outcome using the
Table 1 Dimensions of eating disorder recovery included in operationalizations from 2016 through the current review in 2018

Reference Eating disorder Physical Behavioral Psychological/cognitivea Duration Other/notes

2016
Bang, Rø, and Endestad [17] AN BMI > 18.0 No bingeing, purging, or – 1 year
severely restricted food
intake
Bang, Rø, and Endestad [18] AN BMI > 18.0 No bingeing, purging, – 1 year
excessive or
Curr Psychiatry Rep (2018) 20: 79

compulsive exercise,
or severely restricted
food intake
Bardone-Cone, Butler, Balk, All EDs included BMI ≥ 18.5 No bingeing, purging, or EDE-Q subscale scores 3 months for behaviors;
and Koller [19] fasting within 1 SD of duration of other criteria not
age-matched specified
community norms
Bardone-Cone, Higgins, St. All EDs included BMI ≥ 18.5 No bingeing, purging, or EDE-Q subscale scores 3 months for behaviors;
George, Rosenzweig, fasting within 1 SD of duration of other criteria not
Schaefer, Fitzsimmons-Craft, age-matched specified
and … Preston [20] community norms
Bernardoni, King, Geisler, AN BMI > 18.5 for 18+ No bingeing, purging, or – 6 months for behaviors; unclear
Stein, Jaite, Nätsch, and … years; BMI > 10th restrictive eating if this applied to physical criteria
Ehrlich [21] percentile for patterns
< 18 years; regular
menses
Boehm, Geisler, Tam, King, AN BMI > 18.5 for 18+ No bingeing, purging, or – 6 months for BMI; duration
Ritschel, Seidel, and … years; BMI > 10th substantial restrictive of other criteria not specified
Ehrlich [22] percentile for eating patterns
< 18 years; regular
menses
Dapelo, Hart, Hale Morris, and AN BMI ≥ 18.5 See other EDE-Q scores < 3;unclear 1 year for absence of ED No ED symptoms
Tchanturia [23] if for global score or symptoms; duration of
subscale scores other criteria not specified
Egger, Wild, Zipfel, Junne, AN BMI > 17.5 See other See other Not specified Psychiatric Status Ratings
Konnopka, Schmidt, and … (PSR) ≤ 2—this indicates
König [24] few or no ED symptoms
Ely, Wierenga, and Kaye [25] AN Weight between 90 – – 1 year
and 120% ideal
body weight;
regular menses
Errichiello, Iodice, Bruzzese, AN BMI ≥ 18.5; regular No bingeing or purging – 1 year Referred to as “clinical
Gherghi, and Senatore [26] menses recovery”
Frank, Collier, Shott, and AN BMI between Healthy exercise regime – 1 year
O’Reilly [27] 18.5–24.9; regular and food intake
menses
Frank, Shott, Keffler, and AN Normal weight; Normal exercise patterns – 1 year
Cornier [28] regular menses
Page 3 of 18 79
Table 1 (continued)

Reference Eating disorder Physical Behavioral Psychological/cognitivea Duration Other/notes

Godier, de Wit, Pinto, AN BMI between 18.5 – Global EDE and EDE-Q 1 year for BMI; duration of No longer meeting criteria for an
79 Page 4 of 18

Steinglass, Greene, Scaife, and 25 scores within 1 SD of other criteria not specified ED diagnosis; not meeting criteria
and … Park [29] scores for young for any DSM-IV disorder
women
Hartmann, Zeeck, Herzog, AN BMI > 17.5 See other See other Not specified Psychiatric Status Ratings (PSR) ≤ 2—
Wild, de Zwaan, Herpertz, this indicates few or no ED
and … Löwe [30] symptoms
Las Hayas, Padilla, Barrio, All EDs included See other See other – 1 year No ED symptoms
Beato-Fernandez, Muñoz,
and Gámez-Guadix [31]
Levallius, Roberts, Clinton, and BN, EDNOS See other See other – 90 days No longer meeting criteria for
Norring [32] an ED diagnosis
McAdams, Jeon-Slaughter, AN BMI > 19.0 – – 2 years Explicitly referred to “weight
Evans, Lohrenz, Montague, recovery”
and Krawczyk [33]
Monteleone, Monteleone, AN BMI ≥ 18.5 – – Not specified Explicitly referred to “weight
Serino, Amodio, Monaco, recovery”
and Maj [34]
Mustelin, Latvala, Raevuori, All EDs included Restoration of weight; No bingeing or purging – 1 year for behaviors; unclear
Rose, Kaprio, and return of regular if this applied to physical
Keski-Rahkonen [35] menses (if criterion
applicable)
Mustelin, Lehtokari, and OSFED, UFED Not underweight No bingeing or – 1 year Since symptoms in OSFED and
Keski-Rahkonen [36] inappropriate UFED diagnoses are so varied,
compensatory interviewers used “clinical
behaviors judgment” as part of determining
recovery status
Mustelin, Silén, Raevuori, AN Restoration of weight; No bingeing or purging – 1 year for behaviors;unclear if this
Hoek, Kaprio, and return of regular applied to physical criteria
Keski-Rahkonen [37] menses (if
applicable)
O’Hara, Keyes, Renwick, Giel, AN > 85% of average No bingeing, purging (or EDE-Q scores not 1 year for behaviors; unclear if this
Campbell, and Schmidt [38] body weight other compensatory clinically significant applied to physical criterion;
behaviors), or (i.e., all < 2.80); unclear duration not specified for other
significant restrictive if for global score or criterion
eating patterns subscale scores
O’Hara, Keyes, Renwick, AN > 85% of average No bingeing, purging (or EDE-Q scores not 1 year for behaviors; duration not
Leyton, Campbell, and body weight other compensatory clinically significant specified for other criteria
Schmidt [39] behaviors), or (i.e., all < 2.80); unclear
significant restrictive if for global score or
eating patterns subscale scores
Pfuhl, King, Geisler, AN BMI > 18.5 for 18+ No bingeing, purging, or – 6 months for BMI criterion;
Roschinski, Ritschel, Seidel, years; BMI > 10th significant restrictive duration not specified for menses
and … Ehrlich [40] percentile for eating patterns or behavioral criteria
< 18 years; regular
menses
Curr Psychiatry Rep (2018) 20: 79
Table 1 (continued)
Reference
Phillips, Jimerson, Pillai, and
Wolfe [41]
Scaife, Godier, Reinecke,
Harmer, and Park [42]
Shih, Yang, Morisseau,
German, Scott-Van Zeeland,
Armando, and … Kaye [43]
Shott, Pryor, Yang, and Frank
[44]
Sultson, van Meer, Sanders,
van Elburg, Danner, Hoek,
and … Smeets [45]
Telléus, Fagerlund, Jepsen,
Bentz, Christiansen, Valentin,
and Thomsen [46]
Wild, Friederich, Zipfel,
Resmark, Giel, Teufel, and
… Herzog [47]
2017
Bailer, Price, Meltzer, Wagner, AN
Mathis, Gamst, and Kaye
[48]
Bang, Rø, and Endestad [49]
Bang, Rø, and Endestad [50]
Baucom, Kirby, Fischer,
Baucom, Hamer, and Bulik
[51]
Bentz, M., Guldberg, J.,
Vangkilde, Pedersen, Plessen,
and Jepsen [52]
Bentz, Jepsen, Pedersen, Bulik, AN
Pedersen, Pagsberg, and
Plessen [53]
Eating disorder Physical Behavioral Psychological/cognitivea Duration Other/notes
AN Weight in a normal No bingeing or purging – 8 weeks Explicitly referred to “weight
range recovery” but also had behavior
requirements
AN BMI between No significant eating Global EDE-Q score 1 year for behaviors; duration not
18.5–25.0 disorder pathology within 1 SD of scores specified for other criteria
for young women
Curr Psychiatry Rep (2018) 20: 79
AN BMI ≥ 18.0 – – Not specified; referred to
“maintaining” the required BMI
AN Normal weight for Normal exercise behavior – 1 year
height; regular and food intake
menses
AN BMI > 18.5; regular – See other 1 year Not significantly different from study’s
menses controls on global EDE-Q score
(viewed as confirmation of recovery
rather than an a priori requirement)
AN BMI > 15th – – Not specified Explicitly referred to “weight
percentile, recovery”
corresponding to a
BMI ≥ 18.5 for
ages 18+ years
AN BMI > 17.5 See other See other Not specified Psychiatric Status Ratings (PSR)
≤ 2—this indicates
few or no symptoms
– – – Not specified No definition provided
AN BMI > 18.0 No bingeing, purging, or – 1 year
severe food restriction
AN BMI > 18.0 No bingeing, purging, – 1 year
excessive or
compulsive exercise,
or severely restricted
food intake
AN BMI > 18.5 No bingeing, vomiting, or EDE subscale scores 28 days for psychological criteria; Physical AND (behavioral OR
restrictive eating within 1 SD of duration of physical criterion not psychological criteria) *OR* BMI
population norms specified between 17.5–18.5 AND both
behavioral AND psychological
criteria
AN Normal body weight No eating disorder Global EDE score within 1 1 year for “normal” body No ongoing treatment for an ED;
pathology SD of published mean weight; duration of other criteria “generally favorable outcome”
not specified (≥ 9 points on Morgan-Russell
outcome scores)
Normal body weight No eating disorder Global EDE score within 1 1 year for BMI; 3 months for “Generally favorable outcome”
pathology SD of non-AN norms eating disorder pathology (≥ 9 points on Morgan-Russell
outcome scores)
Page 5 of 18 79
Table 1 (continued)
Reference
Bentz, Jepsen, Telléus, Moslet, AN
Pedersen, Bulik, and Plessen
[54]
Calugi, Ghoch, and Grave [55] AN
Eddy, Tabri, Thomas, Murray, AN, BN
Keshaviah, Hastings, …
Franko [56]
Erdur, Weber, AN
Zimmermann-Viehoff, Rose,
and Deter [57]
Forsberg, Darcy, Bryson, AN
Arnow, Datta, Le Grange,
and Lock [58]
Halvorsen, Reas, Nilsen, and
Rø [59]
Harper, Brodrick, Van
Enkevort, and McAdams
[60]
Kuipers, den Hollander, van der
Ark, and Bekker [61]
Leppanen, Dapelo, Davies,
Lang, Treasure, and
Tchanturia [62]
Martin Monzon, Henderson,
Madden, Macefield, Touyz,
Kohn, and … Hay [63]
Scaife, Godier, Filippini,
Harmer, and Park [64]
Swenne, Parling, and Ros [65] OSFED –AN
Xu, Harper, Van Enkevort,
Latimer, Kelley, and
McAdams [66]
Eating disorder Physical Behavioral Psychological/cognitivea Duration Other/notes
BMI ≥ 18.5 for 16+ No eating disorder Global EDE score within 1 1 year for BMI; duration of “Generally favorable outcome”
79 Page 6 of 18
years; BMI > 25th pathology SD of non-AN mean other criteria not specified (≥ 9 points on Morgan-Russell
percentile, outcome scores)
corrected for age
for 14–15 years
BMI ≥ 18.5 – Global EDE score < 1 SD Not specified Used term “full response” to
of community norms represent highest level of recovery
(i.e., < 1.74)
≥ 95% expected body No binge or purge See other 1 year Psychiatric Status Ratings (PSR) ≤ 2
weight (for AN, per behaviors (for BN)— for both AN and BN—this indicates
PSR) per PSR few or no symptoms
BMI between Normal eating behavior – 5 years
18.5–25.0; regular
menses
≥ 95% of expected – Global EDE score within 1 Not specified This study focused on parent data, but
body weight SD of community linked this to treatment outcome
norms including recovery status of
daughter
AN BMI ≥ 18.5 No bingeing, purging, or EDE-Q global score ≤ 2.5 3 months for behaviors; These criteria were for “fully
other compensatory duration of other criteria recovered.” Also reported on
behaviors not specified “weight recovered” (BMI ≥ 18.5)
AN BMI > 19.0 – – 1 year Explicitly referred to “weight
recovery”
AN, BN See other See other – Not specified No longer meeting criteria for
an ED diagnosis
AN BMI between See other – Not specified No eating disorder symptoms
18.5–25.0
AN ≥ 85% of expected – – Not specified Explicitly referred to “weight
body weight recovery”
AN BMI between No bingeing, purging, Global EDE-Q score 1 year for BMI; duration of other
18.5–25.0 restricting, or within 1 SD of mean criteria not specified
excessive exercise scores for young
women
See other See other Global EDE-Q score < 2 Not specified Also looked at a recovered group
(i.e., the value at or defined by not meeting
below + 1 SD of diagnostic criteria for an ED
adolescent community
norms)
AN Sustained weight See other – Weight recovery and controlled Adequate control of eating
recovery eating disorder symptoms disorder symptoms; explicitly
enabled them to be without referred to “weight recovery”
treatment or only outpatient
treatment for 12 months
following initial study
Curr Psychiatry Rep (2018) 20: 79
Table 1 (continued)

Reference Eating disorder Physical Behavioral Psychological/cognitivea Duration Other/notes

2018
Boehm, Flohr, Steding,
Holzapfel, Seitz, Roessner,
and Ehrlich [67]
AN BMI > 18.5 for 18+ No bingeing, purging, or – 6 months for BMI; duration of
years; BMI > 10th significant restrictive other criteria not specified
percentile for eating patterns
< 18 years; regular
menses
Curr Psychiatry Rep (2018) 20: 79

Castellini, Lelli, Cassioli, AN, BN BMI > 18.5 No objective bingeing, Global EDE-Q score < 1 28 days for behaviors; duration of
Ciampi, Zamponi, Campone, vomiting, or laxative SD above community other criteria not specified
and … Ricca [68] use mean
Franko, Tabri, Keshaviah, AN, BN ≥ 95% expected body No binge or See other 1 year Psychiatric Status Ratings
Murray, Herzog, Thomas, weight (for AN, per purge behaviors (PSR) ≤ 2 for both AN and
and … Eddy [69] PSR) (for BN)—per PSR BN—this indicates few or no
symptoms
Lavagnino, Mwangi, Cao, AN BMI > 18.5; regular Normal exercise behavior – 1 year
Shott, Soares, and Frank [70] menses and food intake
McAdams, Harper, and Van AN BMI > 19.0 – – 2 years Explicitly referred to “weight
Enkevort [71] recovery”

These data come from a PsycINFO search of peer-reviewed, quantitative articles published in 2016–2018 (to date–through March 2018) that explicitly refer to recovery, and not only remission; search terms
were as follows: “anorexia or bulimia or binge eating disorder or eating disorder” and “recovery or recovered.” Terms used in the table represent terms used in the articles (e.g., “normal,” “significant”).
Studies varied in how they did their assessments and how consistent they were in specifying this (e.g., self-report vs. measured weight vs. not indicated; behaviors assessed via structured interview or other
means, specified or not). When recovery criteria were listed as absence of eating disorder symptoms/pathology or no longer meeting criteria for an ED diagnosis, we included that information as “other.”
Some studies reported exclusion criteria for recovery (e.g., no axis I pathology in the past year), but that information is not reported here. Duration reported is in relation to assessment, so 1 year means 1 year
(= 12 months = 52 weeks) prior to assessment; also, durations all refer to a minimum (e.g., “at least” 1 year)
AN anorexia nervosa, BN bulimia nervosa, OSFED other specified feeding or eating disorder, UFED unspecified feeding or eating disorder, ED eating disorder
a
Although duration of psychological/cognitive criteria was generally not specified, when the EDE-Q was used, this can be assumed to refer to the past 28 days
Page 7 of 18 79
79 Page 8 of 18
Morgan-Russell criteria [78]. This will likely be less used
given the removal of amenorrhea as a criterion of AN in the
Diagnostic and Statistical Manual (DSM-5) [79].
For the behavioral criterion of recovery, most research re-
quires abstinence of eating disorder behaviors, but which be-
haviors and how they are assessed varies. For example, since
2016, most research has deemed abstinence from binge eating
and purging as necessary [17, 18, 20–23, 26•, 38, 49, 52, 59,
67, 75, 80], while others include a concession for limited
residual episodes [81, 82]. Some have required abstinence
from restrictive eating patterns [20, 44], and others have not
[59]. Yet others have used additional criteria such as “healthy”
exercise regimens but without operationalization [27, 44].
Ways of assessing eating disorder behaviors have included
the frequencies of objective binge eating, vomiting, and laxa-
tive use in the Eating Disorder Examination-Questionnaire
(EDE-Q) [83], the binge eating module of the Eating
Disorder Examination (EDE) [84], unstructured interviews,
and semi-structured interviews, such as the Eating Disorders
Longitudinal Interval Follow-up Evaluation Interview [85],
which involves annotating calendar months with events sa-
lient to the individual and asking, week by week, about the
presence of any target eating disorder behaviors.
There has been less discussion around constructs that
should be captured as part of psychological recovery, but since
2016, most researchers who examined this component have
focused on eating disorder cognitions. For example, eating
concern, weight concern, shape concern, and a dietary re-
straint mentality are captured in the EDE-Q and the EDE.
Scores similar to community norms (within one standard de-
viation) have been required for all the EDE-Q subscales [20,
51], EDE-Q global score [42, 52, 64, 81, 86–90], and EDE
global score [55, 91–93]. Others have used cut-offs on the
EDE-Q as an index of psychological recovery, including
“non-clinically significant” global scores on the EDE-Q de-
fined as < 2.5 [59], < 2.8 [38], < 2.83 [77], ≤ 3 [23], and < 4
[94]. Some studies on recovery have allowed for the presence
of cognitive symptoms [69•], particularly those that use the
Psychiatric Status Rating Scale (PSR) scores of 2 or less to
define recovery [82, 85] since scores of 2 for AN allow for the
presence of overvaluation of weight/shape, fat phobia, and/or
body image disturbance, and scores of 2 for BN allow for
presence of fighting urges to binge or purge as well as cogni-
tive symptoms. Other studies have used broader indices of
psychological functioning, such as normative scores on all
subscales of the Eating Disorder Inventory-2 [95].
Some research specifies the absence of diagnostic criteria
for any eating disorder, either as the sole criterion for recovery
[96] or in conjunction with other recovery dimensions [6••].
Although studies defining recovery as no longer meeting
DSM criteria address overvaluation of weight/shape [32], this
arguably does not capture the pervasiveness of eating disorder
cognitions that may increase risk for relapse [11]. Thus,
Curr Psychiatry Rep (2018) 20: 79
absence of an eating disorder diagnosis is necessary but not
sufficient. A methodological question is whether this criterion
is best established via clinical interview vs. self-report survey.
Unfortunately, in some of the recovery research, it is un-
clear how recovery was operationalized [48, 50, 70, 97–99].
The absence of detailed information about measurements,
thresholds, and durations stymies replication efforts and the
progression of knowledge.
Duration In addition to the aforementioned issues in
operationalizing recovery, a further significant complexity in-
cludes the duration for which the criteria need to be met. In
some cases, different durations are required for different
criteria (e.g., certain number of months for absence of behav-
iors, but no time frame for cognitions—although those using
the EDE-Q generally involve the past 4 weeks); in some cases,
a duration is required for all criteria; and in some cases, no
duration is specified. Most typically, duration is noted for
eating disorder behaviors. Since 2016, examples of durations
for a behavioral criterion of recovery have included: 1 month
[51], 8 weeks [100], 3 months [20, 59, 76•], 6 months [21, 22,
101], and 12 months [18, 26, 38, 49, 56•, 69, 80, 95].
Franko et al. [69] noted that having to recall symptoms
over a long period of time can create the potential for
recall bias and yield data constrained by the ability to
remember symptoms of interest in the time frame. The
need to balance a sufficiently long duration without symp-
toms with confidence that participants can provide reli-
able and accurate memories over that time period is im-
perative. However, no work has empirically evaluated an
optimal duration of absence of eating disorder behaviors
and cognitions to constitute recovery. Of note, given that
psychological recovery appears to emerge after behavioral
recovery [76•], it can be argued that if psychological re-
covery is assessed, then a shorter duration may be re-
quired for behavioral recovery (with, relatedly, less con-
cerns about bias or forgetting).
Operational Definitions Despite the clinical and academic im-
portance of operationalizing recovery in a consistent manner,
the volume of research on the topic is disappointingly meager,
and the existing work—which is rich and foundational—is not
well-built upon.
Publications addressing recovery almost inevitably stress
the need for uniformity in defining recovery [8].
Importantly, operational definitions have been proposed, i.e.,
[6••, 8••, 10, 14, 102] and at least one working group effort
exists [9]. However, the impact has been limited, as can be
seen in the diversity of definitions displayed in Table 1.
Notwithstanding, the field has operational definitions ripe
for empirical validation and for comparing against each other
to determine which are suitable and best supported by the data
and by clinical reality.
Curr Psychiatry Rep (2018) 20: 79
Table 2 includes proposed operationalizations that have
some validation support and are specific enough to permit
replication. Although most include criteria related to physical,
behavioral, and psychological/cognitive dimensions, there are
some important differences. For instance, Khalsa et al.’s [8••]
definition of recovery was specific to AN, Kordy et al. [9] pre-
sented different definitions by diagnosis (AN-restricting, AN-
binge/purge, BN), and Bardone-Cone et al. [6••] proposed a
transdiagnostic definition to be applied regardless of eating dis-
order diagnosis. The proposals differ by minimum BMI required
for recovery, but most require the absence of eating disorder
behaviors, with some variability in terms of which behaviors
are included. Regarding the psychological component, Khalsa
et al. and Bardone-Cone et al. use an established measure (EDE
and EDE-Q, respectively), while Kordy et al. focus on one con-
struct (e.g., fear of weight gain for AN, preoccupation with
figure for BN). Durations also vary, with absence of eating dis-
order behaviors ranging from 8 weeks to 12 months. Most
groups also provide definitions/operationalizations for a “step
down” from recovery, called “partial recovery” by Khalsa et
al. and Bardone-Cone et al. and “full remission” by Kordy et
al., which also vary in their specific criteria.
Some initial work has begun the necessary comparison
research. Ackard, Richter, Egan, and Cronemeyer [104] tested
a variety of definitions of remission in a female sample with a
history of AN, BN, or EDNOS who had participated in an
eating disorder treatment outcome study. Included in the com-
parisons were: absence of a DSM eating disorder; Morgan-
Russell criteria [78]; and criteria set forth by Pike [10], Kordy
et al. [9], and Bardone-Cone et al. [6••]. Although the authors
refer to remission, it appears that recovery was compared,
albeit not always with the durations specified (e.g., for
Kordy et al., duration of recovery applied was 3 months rather
than the 12 months recommended). Ackard et al. [96] argue
that a robust definition of remission would “prove applicable
for each ED diagnosis, demonstrate moderate to high agree
agreement with other remission definitions and particularly
across each ED diagnosis, including a measure of psycholog-
ical wellbeing, and distinguish between remitted and not re-
mitted patients on quality of life”—with these guidelines in
mind and based on their empirical findings, they recommend
adopting the Bardone-Cone et al. [6••] criteria for assessing
recovery. More work comparing operationalizations is need-
ed, including longitudinal work to test the predictive validity
of definitions (i.e., a valid definition should be associated with
low relapse rates).
Of note, to date, operationalizations of recovery have not
included broad well-being as a criterion. We argue that exam-
ining well-being is important in understanding recovery and
as a target of intervention and monitoring, but should not be
part of the definition, given that non-eating disorder-related
factors could be responsible for well-being, including psychi-
atric comorbidity.
Page 9 of 18 79
Predictors of Recovery
Depending on the definition of recovery or “good outcome,”
many factors have been implicated as being related to better
outcome. Such factors include, but are not limited to, mother-
hood [76], selflessness [95], extraversion and assertiveness
[32], and less impulsivity [88]. Franko et al. [69] found dif-
ferent predictors of outcome at a 22-year follow-up, depend-
ing on diagnosis. A comorbid major depressive disorder at
intake predicted having AN-restricting subtype at follow-up,
an older age at intake and greater severity of AN or BN symp-
toms at intake assessment predicted having AN-binge/purge
subtype, and greater severity of BN symptoms at intake pre-
dicted having BN, suggesting the need to address these fea-
tures to promote recovery. The depression finding is in line
with work by Keski-Rahkonen and colleagues [105] who
found that the strongest predictor of failure to recover was
premorbid depression.
With some exceptions—possibly premorbid depression
[69, 105]—the literature is lacking in replication of significant
predictors. Lack of replication is likely due to the lack of
consensus in defining and operationalizing recovery and dif-
ferences in samples. Replication studies using the same con-
ceptualization of recovery are needed to provide more con-
vincing support for useful predictors that would inform inter-
vention efforts and psychoeducation.
With the caveat of variable recovery definitions, Vall and
Wade [106] performed a meta-analysis to evaluate predictors
of treatment outcome. They found support for the following in
predicting better outcomes (but not necessarily recovery):
greater motivation to recover, fewer comorbidities, lower de-
pression, less severe eating pathology (fewer binge/purge be-
haviors, lower weight/shape concern), higher BMI, better in-
terpersonal functioning, and fewer family problems.
Recovery and Biological
and Neuropsychological Markers
Recent recovery research tries to elucidate whether there are
biological differences between recovered individuals and
those with a current eating disorder, as a way to tease apart
whether biological/neuropsychological markers are state-
related (and resolve with eating disorder recovery) or possible
precursors (e.g., premorbid features that may serve as poten-
tial risk factors for eating disorders) or scars of the eating
disorder (e.g., a consequence of the eating disorder that re-
mains even after an eating disorder has been resolved). Of
note, if individuals recovered from an eating disorder look
similar to those with an eating disorder on a biological feature
or neuropsychological marker, although that provides evi-
dence against a state-related effect, it cannot distinguish be-
tween a premorbid biological difference and a scar effect,
79 Page 10 of 18 Curr Psychiatry Rep (2018) 20: 79

absent longitudinal data collected prior to the development of
the eating disorder.
Fuglset, Landro, Reas, and Ro [107] reviewed neuroimag-
ing studies (n = 14) of individuals recovered from AN.
Neuroimaging techniques (e.g., fMRI) investigated neural ac-
tivation in response to visual processing of one’s own and
other’s bodies/appearance, food stimuli, gustatory processing,
and emotional stimuli. Additionally, these authors reviewed
neuroimaging studies involving the neurobiological reward
system and executive functioning (i.e., set-shifting, working
memory, inhibitory control). However, how recovery was de-
fined was not made explicit, and Fuglset et al. also noted the
difficulty in synthesizing findings due to the inconsistent par-
adigms used to assess neurobiological processes, making the
findings difficult to interpret. With these caveats in mind, there
were significant differences that emerged, often in study de-
signs comparing individuals recovered from AN and controls.
For example, in Fuglset et al.’s review [107], they reported
research that recovered individuals demonstrated: increased
activation in visual processing regions in response to viewing
faces, elevated activation in the ventral anterior insula (impli-
cated in processes related to focal attention) in anticipation of
seeing images of food, and reduced activity in the medial
prefrontal cortex (which mediates decision-making) in the
context of an inhibition task. Thus, this literature has identified
biological/neuropsychological mechanisms that may underlie
or maintain some of the symptoms of AN.
Some recent findings suggest that biological or neurologi-
cal deficits may be a premorbid feature or a scar of eating
disorders (i.e., serum zinc, brain connectivity in specific

Table 2 Operationalizations proposed with some validation support that are specific enough to permit replication

Pike [10] Kordy et al. [9] Couturier and Lock [5]

ED diagnoses addressed AN AN-restricting, AN-binge/purge, BN AN (in adolescents)

Criteria for full recovery
Physical BMI ≥ 20 or ≥ 90% of recommended weight; > 191,2 ; unspecified3 ≥ 90% of ideal body
normal menstrual functioning; weight
absence of acute medical problems
related to AN (excludes long-term
problems such as osteoporosis)
Behavioral Absence of compensatory behaviors Absence of binging2,3; absence of
vomiting or laxative abuse1,2,3
Psychological A RCI ≥ 1.96 and a score more likely to be No extreme fear of weight gain1,2; Restraint subscale
drawn from the functional than no extreme preoccupation of within 1 SD of
dysfunctional population on measures of shape and weight3 community norms
(a) weight and shape concerns
(i.e., EDE Weight Concern and Shape
Concern subscales, Body Shape
Questionnaire, Mizes Anorectic
Cognitions Scale) and dietary restriction
(i.e., EDE Restraint, EDI Drive for Thinness
subscale; Eating Inventory Restraint subscale)
Duration Minimum of 8 weeks 12 months1,2,3 Unspecified
Other illness statuses Initial treatment response, relapse, remission Full remission, partial remission,
defined relapse, and recurrence

Bardone-Cone et al. [6••] Khalsa et al. [8••]

ED diagnoses addressed Transdiagnostic AN
Criteria for full recovery
Physical BMI ≥ 18.5 BMI ≥ 20 or ≥ 85% of ideal body weight
Behavioral Absence of bingeing, purging, or fasting; not No restricting, bingeing, or purging
meeting criteria for current eating disorder
Psychological EDE-Q subscales within 1 SD of age-matched EDE within 1 SD of normal
norm
Duration 3 months for behavioral criteria; 1 month for 12 months
psychological
Other illness Partially recovered, active eating disorder Partial recovery, full remission, partial
statuses defined remission, partial relapse, and full
relapse

For Kordy et al. [9], 1 indicates criteria for AN-restricting, 2 indicates criteria for AN-binge/purge, and 3 indicates criteria for BN
RCI reliable change index as described by Jacobson and Truax [103]
Curr Psychiatry Rep (2018) 20: 79
regions, gray matter)—that is, that these biological/
neurological features remain in recovery [64, 80]. However,
there is also evidence that recovery is associated with normal-
ization of a wide host of neurobiological markers (i.e., cortical
thickness, white matter microstructure, olfactory sensitivity)
[21, 49, 52, 70]. Some studies show mixed evidence, with
restoration in some indices (i.e., gray matter, brain connectiv-
ity) but not in others that are related or are in related regions
[22, 63].
Recent work has examined an array of neuropsychological
features, often in conjunction with other constructs, with in-
teresting implications. For example, anxiety appears to influ-
ence cognitive inhibition in those remitted from AN [25];
since elevated cognitive inhibition contributes to the cognitive
rigidity, proposed as an endophenotype of AN [108], knowing
that anxiety exacerbates cognitive inhibition bolsters the need
to treat anxiety as part of treating AN. In another finding,
higher activation in frontal regions during a visual stimulus
processing task was associated with poor set-shifting in fe-
males recovered from AN [45]. This finding highlights the
different but related mechanisms that may serve to maintain
symptoms of AN, since both the enhanced cognitive control
linked to the brain activation and the cognitive rigidity inher-
ent in poor set-shifting may contribute to rigid control over
food intake, including in the context of visual cues of food.
Interestingly, recent research found no differences between
individuals with first-episode AN, recovered from AN, or
controls on set-shifting, working memory, sustained attention,
and processing [54]. Importantly, this was in a sample of ad-
olescents and young adults. The authors suggest that some
neuropsychological differences may be related to longer pe-
riods of starvation and appear later in adulthood as a scar,
providing a window of opportunity for neuropsychological
intervention (e.g., cognitive remediation) earlier in the disor-
der, or that abnormalities may not be detectable until the at-
tainment of fuller maturation.
In summary, it appears that some biological and neuropsy-
chological differences suggest possible trait vulnerabilities for
eating disorders, and some abnormalities observed in patients
with eating disorders normalize following a period of recov-
ery. Limitations of this body of work include the focus on AN
and the tendency to not explicitly describe recovery
operationalization. With consensus recovery criteria applied,
the neurobiological underpinnings of recovery seem ripe for
further investigation.
Severe and Enduring Anorexia Nervosa
How do individuals with severe and enduring AN (SE-AN) fit
into thinking about recovery? Calugi and colleagues [55]
found that individuals with SE-AN (duration of illness >
7 years) and those with AN not characterized as severe and
Page 11 of 18 79
enduring showed comparable recovery rates at 12-month fol-
low-up, challenging the idea that SE-AN is intractable to good
therapeutic outcomes. Likewise, Eddy and colleagues [56]
found that of those with AN who were not recovered at a 9-
year follow-up, half attained recovery at a 22-year follow-up.
These findings align with earlier work suggesting that those
with SE-AN were able to attain full recovery across physical,
behavioral, and psychological dimensions [109], providing
optimism even among longstanding cases of AN and raising
questions about best ways to intervene. At what point, if any,
might a shift occur away from staying the course with more
active treatment and the goal of recovery toward a primary
focus on quality of life? [110].
Qualitative Perspectives on Recovery
Qualitative research on patients’ perspectives on eating disor-
der recovery is important in developing meaningful
operationalizations of recovery. Findings from qualitative
studies are constrained, however, by small sample sizes and
participants self-identifying as recovered or in recovery (most
often from AN) rather than as a result of an assessment.
One main finding identified from these studies was that the
clinical reliance on biometrics (i.e., weight) and food intake,
was insufficient, and does not address the psychological part
of recovery [111, 112]. In their qualitative meta-analysis, de
Vos and colleagues [15••] reviewed 18 studies that included
286 recovered individuals to find that psychological well-
being was the most endorsed criterion (making up 52% of
recovery criteria endorsed), followed by reduction in eating
disorder pathology, including behaviors, cognitions, and
physical components (21% of criteria). Additionally, in a
unique qualitative study of women who identified as recov-
ered and met physical, behavioral, and psychological criteria
for recovery, participants reported a “reprogramming” via al-
tered thinking as a key indicator of recovery [109].
A second key finding from these studies is that recovery is a
process and not just an outcome. Hence, examining pathways
to recovery (i.e., cultivating hope, developing self-compassion,
benefiting from the support of others, and more specific pro-
cesses such as metamorphosing pride in AN to pride in self) is
important in addition to understanding what recovery “looks”
like (outcome) [113–115]. Combining the importance of hope
and support of others, preliminary work has shown that having
a recovered mentor available to instill hope that recovery is
possible was important to promoting recovery [99].
Future Directions
Consensus Definition Unquestionably, the most important fu-
ture direction revolves around establishing a uniform,
79 Page 12 of 18
universal definition of recovery for the advancement of sci-
ence and clinical practice. Note that, given the absences of
such a consensus, all the findings reviewed above come with
the caveat that results might be different, depending on the
definition and operationalization of recovery. It is troubling
when virtually every publication reporting on recovery fore-
grounds the varying definitions of recovery as problematic,
and yet, as a field, this is a “broken record” that we keep
playing. This is a problem. However, there is a solution.
Given the presence of specific operationalizations of recov-
ery with validation [6, 8, 9], these should continue to be exam-
ined and compared. Decision-making related to what emerges
as a consensus definition should rely on data demonstrating
both concurrent validity cross-sectionally and predictive valid-
ity longitudinally (e.g., examining the stability of recovery).
Researchers should also consider which definitions/
operationalizations are most associated with common themes
from patients’ reports, including self-acceptance and quality of
life. Lastly, for criteria where normative levels are desired for
recovery (e.g., eating disorder cognitions), population norms
that are age-matched and gender-matched are ideal [65].
In arriving at a consensus definition, it is worth considering
dissemination of research findings into practice and other re-
search studies. The public health impact of a treatment approach
can be expressed as the product of the effectiveness of the inter-
vention and its reach [116]. Similarly, it can be argued that the
public health impact of recovery definitions/operationalizations
results from the product of the validity of such definitions/
operationalizations and their reach. Thus, if a validated defini-
tion of recovery is not widely disseminated and applied consis-
tently in treatment outcome research, then the impact of this
knowledge will be limited and, more specifically, the field will
continue to be hamstrung by inconsistency. A contributor to
successful dissemination is “real world usability” [117], which
includes consideration of cost and training needed. Being able to
assess recovery criteria in a logistically streamlined way (such as
assessing cognitions with the EDE-Q) should improve the reach
of a consensus definition of recovery.
In addition to the need for a consensus definition of recovery,
there is also the need for consensus terminology of terms such
as recovery, partial recovery, remission, and relapse. For exam-
ple, using the same dataset and the same criteria for outcome,
different authors have referred to the same group as “recovered”
and “remitted” [56, 69]. While in some work, the idea of “par-
tial recovery” refers to some but not all aspects of recovery
attained (physical and behavioral but not cognitive recovery
[6••]), and in other work, partial and full recovery require iden-
tical criteria except that the duration of the criteria is longer for
recovery [8••]. Consistent terminology would aid in communi-
cation among clinicians, patients, families, and researchers.
Why have existing operationalizations with evidence of
validity not had greater impact on recovery research? This
could be due to researchers tending to stick with
Curr Psychiatry Rep (2018) 20: 79
assessments they are familiar with or due to recovery ques-
tions emerging post hoc without being able to planfully
include relevant measures. Additionally, differing research
goals may prove a challenge to the universal adoption of a
recovery definition. For example, a research team interested
in the impact of physiological changes among those with
AN may have a rationale for focusing on “weight-recov-
ered” individuals, researchers engaged in a treatment out-
come study may want to include in a recovery definition
aspects that they hypothesize their treatment condition
would alter, and research involving community samples
may be motivated to examine the day to day lived experi-
ences of recovery which they may feel requires a quality of
life dimension as part of the recovery definition. Thus, it is
possible that, given the reality of different motivations
across studies, some would feel constrained by a universal-
ly adopted definition. This is important to acknowledge, but
should be weighed against what could be gained by having
a consensus definition to meaningfully compare study find-
ings (and what is lost by not having an even playing field
for comparison). Perhaps researchers could be encouraged
to report findings both from a consensus definition and, if
they so wish, from a variant that is of particular interest to
them—or to include these other constructs as validation
criteria for a consensus definition of recovery.
Researchers have stressed the need for leadership from
clinical and research organizations (e.g., Academy for
Eating Disorders, National Eating Disorders Association,
Eating Disorders Research Society) to support a standard-
ized consensus definition for it to be successfully widely
adopted and have an impact [8••, 14]. Specialty profes-
sional journals (e.g., International Journal of Eating
Disorders) could also give much needed leadership in this
area by encouraging research on operationalization/
validation (i.e., special issue) and ensuring that “recov-
ered” samples are operationalized sufficiently for replica-
tion and in line with the current conceptualization (i.e.,
combination of physical, behavioral, psychological/
cognitive).
Transdiagnostic or Tailored to Specific Eating Disorders?
Should we be looking for one definition/operationalization
of recovery to apply to all eating disorder diagnoses? In their
qualitative meta-analysis, de Vos et al. [15••] intentionally
included studies regardless of eating disorder diagnoses
since their interest was in overall criteria for eating disorder
recovery. Bardone-Cone et al. [6••] have also argued for the
benefit of one set of criteria so as to capture all eating dis-
orders, given the relatively common experience of diagnos-
tic migration and symptom fluctuation [118]. There is also
value in parsimony. Rather than modifying definitions to fit
AN, BN, binge eating disorder (BED), and other eating
disorders, having one conceptualization makes it easier to
Curr Psychiatry Rep (2018) 20: 79
communicate what recovery means and make comparisons.
Importantly, even if one were to use a transdiagnostic def-
inition of recovery applicable across eating disorders, that
does not imply that predictors of such recovery would be
the same across diagnoses. Indeed, Lock et al. [14] found
different predictors of full recovery (physical, behavioral,
psychological): end of treatment weight gain best predicted
recovery for those with AN and decreased rates of purging
to less than 2×/month at end of treatment best predicted
recovery among those with BN. Nonetheless, future re-
search should examine whether tailored definitions of re-
covery are more valid than a transdiagnostic approach.
Process of Recovery Recovery is both a process and a state/
outcome, with the process dimension especially empha-
sized in qualitative research with individuals who self-
identify as recovered (e.g., recovery as a “journey”).
Examining the impact of process variables empirically is
warranted (e.g., fostering the evolution of source of pride
and self-concept across treatment; realistically promoting
hope; boosting self-acceptance). This could inform specific
aspects of intervention to focus on or develop in relation to
the outcome of recovery.
Full Recovery for All? Should this concept of full recovery be
something to aim for with all of our patients? The argument
for an affirmative response is that we do not want to have
patients settle for something less which might increase risk
for relapse. Further, evidence indicates that even particularly
severe cases can attain this high level of recovery [109], and
much of the qualitative work since 2016 has highlighted the
value of hope and being able to envision recovery as possible
[102, 113, 114, 119]. The argument against aiming for full
recovery for all is that, realistically, some individuals may
experience residual eating disorder cognitions throughout
their lives and that, for these individuals, providing tools to
prevent their thoughts from transforming into actions (behav-
ioral symptoms) may be the most feasible and helpful ap-
proach. The challenge would be in how to determine that an
intervention aimed at attaining cognitive recovery should end
or transition to a different approach.
Diversity of Samples Most recovery research recruits indi-
viduals who presented for treatment at an eating disorder
clinic. However, only about 50% of cases of AN are de-
tected in the healthcare/medical system [120] and only a
minority of these are seen for treatment in a specialty clinic
[121]; thus, our understanding of recovery has generally
been limited to those seeking treatment through eating dis-
order clinics/centers. Given the existence of “spontaneous”
recovery unrelated to treatment [122], we might wonder if
a definition of recovery that is valid in treatment-seeking
samples is valid in those who recover without treatment.
Page 13 of 18 79
Also, it is striking how many recent studies on recovery
focus solely on AN (80%); thus, recovery is much less
examined for BN, BED, other specified feeding or eating
disorder (OSFED), and unspecified feeding or eating dis-
order (UFED).
Recovery research has also predominantly focused on ad-
olescents and young adults, females, and Caucasian popula-
tions; this mirrors eating disorder research on topics other than
recovery. It has been well-established that eating disorders
occur across the age span, affect males, and are experienced
by individuals of diverse racial and ethnic backgrounds. What
is not known is whether current conceptualizations and
operationalizations of recovery are valid across these diverse
groups. Relatedly, we do not know if predictors of recovery
differ across groups. Cultural factors may facilitate recovery
or present additional barriers. For example, if eating disorders
are less recognized in racial/ethnic minority groups (e.g., few-
er referrals), then they will likely begin treatment at a later age,
with implications for poorer outcomes [76•].
How the sample of controls is selected also warrants men-
tion. If a research question requires comparing a recovered
group to controls, efforts should be made to match controls
on key demographic variables of the recovered sample (e.g.,
age, gender). Although many researchers select controls with
no current or history of eating disorders or any psychological
disorder, we believe this is ill-advised. Individuals with no
history of any psychopathology are not very representative
of the population. Further, comparing to individuals so free
of psychopathology arguably makes it easier to find differ-
ences; more rigorous would be for comparison samples to
have no history of eating pathology but be otherwise repre-
sentative of the diversity of psychopathology. A related impli-
cation of using “super-healthy” controls is that recovered in-
dividuals are not being compared to normative expectations
but rather to a higher, and less epidemiologically likely, stan-
dard given the known prevalence of psychological disorders
[123]. Also, if recovery findings differ across studies that use
the same consensus definition but different ways of defining
controls (i.e., no eating disorder pathology vs. no psychopa-
thology of any kind), discrepant findings could be due to the
control group differences. For example, studies using certain
types of methods (e.g., neuroimaging) may recruit super-
healthy control participants to maximize the likelihood of de-
tecting group differences [124].
Mediators and Moderators Examining mediators and moder-
ators of recovery has not been extensively examined. Once a
consensus definition of recovery has been adopted, this will be
an important future avenue, especially in intervention work.
For example, if we knew for whom certain interventions more
likely lead to recovery (moderator model), we could provide
better referrals to match patients to treatment. And if we could
determine which factors are changed by an intervention to
79 Page 14 of 18
form a pathway to recovery (mediator model), we could mod-
ify treatments to target those factors. A review paper [125]
sought to identify mediators and moderators of cognitive be-
havioral therapy for eating disorders. Regarding mediators,
they found that early changes in behavioral and cognitive
symptoms led to better outcomes in these dimensions across
eating disorder diagnoses. However, they were unable to iden-
tify consistent moderators of outcome and noted that a possi-
ble reason was due to the widely varying definitions of out-
come. Researchers examining moderator and mediator
models are urged to select moderators and mediators on the
basis of theory rather than convenience.
Conclusions
Based on this review of recent research, we conclude that a
suitable conceptualization of recovery will include assessment
of physical, behavioral, and (eating disorder-specific)
psychological/cognitive domains, as well as absence of any
eating disorder (not only the presenting eating disorder).
Further, we recommend a conceptualization that can be ap-
plied transdiagnostically for parsimony and given the reality
of diagnostic migration. Useful adjuncts that are relevant to
understanding recovery but are not incorporated within the
definition of recovery include quality of life and broader psy-
chological well-being (i.e., comorbid psychopathology, self-
a c c e p t a n c e ) . Wi t h o u t a s t a n d a r d d e f i n i t i o n a n d
operationalization of recovery, research progress is hampered,
but confusion about what recovery means may also translate
to potential harms for patients by spilling over into clinical
practice, for instance, by unintentionally squelching hope.
For example, Rance, Moller, and Clarke [112] reported that
one patient noted: “I very much got the message from the
eating disorder service that an eating disorder was something
I managed for the rest of my life…and I didn’t even know like
you could ever get fully better” (p. 589).
Several operationalizations of recovery that are specific
enough to permit testing and replication have been proposed
[5, 6, 8–10, 102]. Building on previous validation testing [6••,
9, 14] will clarify the direction of most value for the eating
disorder field. Once this has been achieved, more progress
will be able to be made on an array of critical topics: identi-
fying predictors of recovery, biological and neurological
markers, treatments most strongly associated with recovery,
and similarities/differences across diverse samples. Clinically,
adopting a standardized definition does not negate the impor-
tance of attending to the personal meaning of recovery for
patients. While developing a standardized definition would
overcome a major barrier in the eating disorders field and have
far-reaching clinical implications, recovery remains a highly
personal experience.
Curr Psychiatry Rep (2018) 20: 79
Acknowledgements NIH Grant R01 MH095860 to Anna M. Bardone-
Cone (PI).
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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