Journal of Psychopathology and Clinical Science

© 2024 American Psychological Association 2024, Vol. 133, No. 3, 285–296

ISSN: 2769-7541 https://doi.org/10.1037/abn0000912

“Terminal Anorexia Nervosa” May Not Be Terminal: An Empirical Evaluation

Morgan Robison1, Nikhila S. Udupa1, Sophie R. Abber1, Alan Duffy2, 3, Megan Riddle4, 5,
Jamie Manwaring2, 3, 4, Renee D. Rienecke2, 3, 6, Patricia Westmoreland4, Dan V. Blalock7, 8,
Daniel Le Grange9, 10, Philip S. Mehler2, 3, 4, 11, and Thomas E. Joiner1
1
Department of Psychology, Florida State University
2
Eating Recovery Center, Denver, Colorado, United States
3
Pathlight Mood and Anxiety Center, Denver, Colorado, United States
4
ACUTE at Denver Health, Denver, Colorado, United States
5
Department of Psychiatry and Behavioral Sciences, University of Washington
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

6
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Department of Psychiatry and Behavioral Sciences, Northwestern University

7
Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans
Affairs Medical Center, Durham, North Carolina, United States.
8
Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine
9
Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine
10
Department of Psychiatry and Behavioral Neuroscience, The University of Chicago
11
Department of Internal Medicine, University of Colorado School of Medicine

Gaudiani et al. (2022) presented terminal anorexia nervosa (T-AN) as a potential new specifier to the
anorexia nervosa (AN) diagnosis, with criteria including (a) AN diagnosis, (b) age . 30 years, (c)
previously participated in high-quality care, and (d) the clear, consistent determination by a patient with
decision-making capacity that additional treatment would be futile, knowing death will result. This study’s
purpose was to empirically examine a subgroup of participants with AN who met the first three criteria of
T-AN—and a smaller subset who also met a proxy index of the fourth criterion involving death (TD-AN)—
and compare them to an adult “not terminal” anorexia nervosa (NT-AN) group and to a “not terminal” subset
30 years of age or older (NTO-AN). Patients at U.S. eating disorder treatment facilities (N = 782; T-AN: n =
51, TD-AN: n = 16, NT-AN: n = 731, NTO-AN: n = 133), all of whom met criteria for a current Diagnostic
and Statistical Manual of Mental Disorders, 5th Edition diagnosis of AN, were compared regarding admis-
sion, discharge, and changes from admission to discharge on physiological indices (i.e., white blood cell
counts, albumin levels, aspartate aminotransferase levels, and body mass index), as well as self-report
measures (i.e., eating disorder, depression, anxiety, and obsessive-compulsive symptoms). In contrast to
the tight syndromal symptom interconnections of, and inevitable spiral toward death expected for, a terminal
diagnosis, results suggest substantial variability within the T-AN group and TD-AN subset, and an overall
trend of improvement across physiological and self-report measures. This study thus provides some
empirical evidence against the specification of the T-AN diagnosis.

Morgan Robison served as lead for conceptualization, formal analysis,

Morgan Robison https://orcid.org/0000-0002-8685-9259
Morgan Robison was supported by the National Institute of Mental Health
(Grant 5T32MH093311-12). Opinions, interpretations, conclusions, and
recommendations are those of the authors and are not necessarily endorsed
by the National Institute of Mental Health. Dan V. Blalock was supported
by Career Development Award 19-035 (IK2HX003085-01A2) from
the U.S. Department of Veterans Affairs Health Services Research and
Development Service. Renee D. Rienecke receives consulting fees from
the Training Institute for Child and Adolescent Eating Disorders, LLC, and
receives royalties from Routledge. Daniel Le Grange receives Royalties
from Guilford Press and Routledge, is a codirector of the Training Institute
for Child and Adolescent Eating Disorders, LLC, and is a member of the
Clinical Advisory Board at Equip Health. The remaining authors declare
that they have no conflicts of interest. These results have not been previously
disseminated, and the data are not available (i.e., data involve medical health
records, and participants did not consent to de-identified public data sharing),
but materials and code are accessible by contacting the corresponding author.
Hypotheses and analyses were not preregistered.
investigation, visualization, writing–original draft, and writing–review and
editing. Nikhila S. Udupa and Sophie R. Abber served in a supporting role
for conceptualization, writing–original draft, and writing–review and editing.
Alan Duffy served as lead for data curation and served in a supporting role for
methodology, project administration, and writing–review and editing. Megan
Riddle and Daniel Le Grange served in a supporting role for conceptualiza-
tion and writing–review and editing. Jamie Manwaring, Renee D. Rienecke,
and Patricia Westmoreland served in a supporting role for writing–review and
editing. Dan V. Blalock served in a supporting role for formal analysis and
writing–review and editing. Philip S. Mehler served in a supporting role
for conceptualization, methodology, supervision, and writing–review and
editing. Thomas E. Joiner served as lead for supervision and served in a sup-
porting role for conceptualization, formal analysis, investigation, writing–
original draft, and writing–review and editing.
Correspondence concerning this article should be addressed to Morgan
Robison, Department of Psychology, Florida State University, 1107 West
Call Street, Tallahassee, FL 32306-4301, United States. Email: mrobison@
psy.fsu.edu

285
 286 ROBISON ET AL.

General Scientific Summary

“Terminal” is a proposed new specifier for an anorexia nervosa (AN) diagnosis with the following cri-
teria: (a) diagnosis of AN, (b) over 30 years old, (c) previously repeatedly sought high-quality treatment,
and (d) desire to fatally discontinue treatment. This study empirically scrutinizes the “terminal” label for
AN by comparing those with AN who meet the “terminal” criteria to those who do not. Findings here
suggest that the groups meeting three-criteria T-AN (as well as those meeting a proxy of the fourth cri-
terion) show substantial variability in admission, discharge, and treatment response on physiological
and self-report measures, overall indicating improvement that is inconsistent with a terminal pattern
for this group.

Keywords: terminal anorexia nervosa, anorexia nervosa, eating disorder features

Supplemental materials: https://doi.org/10.1037/abn0000912.supp

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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Anorexia nervosa (AN) is a severe psychiatric disorder character-
ized by significant restriction of food intake leading to objectively
low body weight, fear of weight gain, and body image disturbance
(American Psychiatric Association [APA], 2013). AN has the high-
est mortality rate of any psychiatric illness other than opiate use dis-
order; outcomes tend to be suboptimal (Birmingham et al., 2005;
Harbottle et al., 2008), with more than half of individuals failing
to achieve remission after treatment (Watson & Bulik, 2013).
Even the best evidence-based treatments for AN may confer little
advantage over comparator treatments in the long term (Murray
et al., 2019). Moreover, a review from the early 21st century reported
that outcomes for AN have not improved significantly in the prior
50 years (Steinhausen, 2002).
A high proportion of individuals with AN develop a chronic
course, with some studies suggesting that approximately 20% fall
into this category (Steinhausen, 2002). There is a growing body of
literature on the concept of severe and enduring AN (SE-AN),
which has been defined as a form of AN with a debilitating, persis-
tent course that may not respond to treatment (Touyz & Hay, 2015;
Touyz et al., 2013; Wonderlich et al., 2020). While there is no formal
consensus on a definition of SE-AN, Hay and Touyz (2018) pro-
posed the following criteria: (a) clinically significant functional
impact; (b) at least a 3-year duration of illness; and (c) exposure to
at least two evidence-based treatments (Hay & Touyz, 2018).
While SE-AN is clearly a debilitating illness and many do not
recover or may die due to complications of AN, some work suggests
that most individuals with a protracted illness course do recover
(Eddy et al., 2017).
Gaudiani et al. (2022) proposed a presentation more extreme than
SE-AN, terminal AN (T-AN). The authors define those with T-AN
as: (a) having a diagnosis of AN; (b) being age 30 or older; (c) hav-
ing persistently engaged in high-quality, multidisciplinary care; and
(d) persistent denial of further treatment, knowing death is the inev-
itable outcome, while having intact decision-making abilities
(Gaudiani et al., 2022). These criteria overlap somewhat with
those proposed for SE-AN, including history of engagement in treat-
ment and chronicity (defined in SE-AN by duration of illness and in
T-AN by age), but the concept of T-AN substantially diverges from
SE-AN in the conceptualization of death as an inevitable option for
those with a poor prognosis. Gaudiani et al. (2022) described three
individuals who died of chronic AN and proposed that individuals
who meet their definition of T-AN should have a right to medical
aid in dying in states where it is legal.
To the best of our knowledge, six papers thus far have already been
published in response, raising several concerns with this newly dis-
cussed construct of T-AN. First, the ability to define “terminal” in
the context of AN was raised as a potential problem (Crow et al.,
2023; Guarda et al., 2022; Riddle et al., 2022). Second, Riddle et
al. (2022) and Guarda et al. (2022) suggest that some individuals
with T-AN, as defined by Gaudiani et al. (2022), may have a treatable
illness. Third, others discussed the potential dangers of a terminal
label for AN, particularly given its implications regarding hopeless-
ness, and for a terminal label becoming something that individuals
with AN strive for given the ego-syntonic nature of the disorder
(Downs et al., 2023; Elwyn, 2023; Guarda et al., 2022). With these
concerns in mind, Yager et al. (2022) published a response, suggest-
ing that T-AN can be adequately defined, AN can be both treatable
and terminal, and that the terminal label itself is not dangerous.
Although many papers have been published in response to
Gaudiani et al.’ (2022) proposition, to our knowledge, no one has
examined objective indicators of terminality that would be observed
if T-AN is a valid categorization. We recognize that the field’s lack
of an empirical approach to T-AN may be due to its inherently non-
empirical, philosophical qualities, and that our approach herein
should be contextualized within that view. Nonetheless, in untreat-
able instances of a terminal illness, one is likely to observe cohering,
objective indicators of terminality when, for instance, assessing
bloodwork. For example, albumin levels among end-stage cancer
patients and human immunodeficiency virus (HIV) are well below
healthy ranges (Feldman et al., 2003; Goldwasser & Feldman,
1997; Hall & Cash, 2012; Mehta et al., 2006). Both albumin and
aspartate aminotransferase (AST) levels can reflect liver functioning;
like low albumin levels, high AST levels may indicate near-death
status (Goldwasser & Feldman, 1997; Hall & Cash, 2012). There
is a pattern of biological objectivity and increasing network density
of disease-related parameters within truly terminal illnesses, param-
eters that should replicate across the definition of “terminal.”
Furthermore, defining any psychiatric condition as “terminal” has
wide-reaching and concerning implications. Importantly, the sug-
gestions made by Gaudiani et al. (2022) could be generalizable to
other Diagnostic and Statistical Manual of Mental Disorders, 5th
Edition (DSM-5) diagnoses, such as schizophrenia and bipolar dis-
order, and thus empirically testing claims such as these is essential
to direct clinical and ethical guidelines for treatment (Gaudiani
et al., 2022). Socially, identifying any mental illness as “terminal”
has significant implications for the patient, their family, their
 TERMINAL ANOREXIA NERVOSA
community, and society at large (Downs, 2023). Given the contro-
versy over the construct of T-AN, empirical research is needed to
assess the validity and utility of this label. To our knowledge, no
study has empirically tested a definition of T-AN by examining
whether individuals who meet these criteria form a relatively
homogenous group that does not improve with treatment.
In the present study, we sought to further examine the terminality
concept within an adult AN sample, operationalized in one set of anal-
yses using three of the four criteria suggested by Gaudiani et al. (2022;
i.e., diagnosis of AN, age of 30 or older, and prior persistent engage-
ment in high-quality eating disorder care; T-AN), and in a subset of
T-AN that demonstrated desire for death, a proxy index of the fourth
criterion (T-AN—and a smaller subset who also met a proxy index
of the fourth criterion involving death [TD-AN]). We sought to com-
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pare this “terminal” group and subset (T-AN and TD-AN) to a “not
This document is copyrighted by the American Psychological Association or one of its allied publishers.
terminal” AN group (NT-AN; i.e., adults [18+] who do not meet all
of the first three criteria for terminality), and to a subset of the “not ter-
minal” group who were 30 years of age or older (NTO-AN).
We reasoned that if the “terminal” groups are found to be relatively
homogenous regarding biological and clinical variables at admission,
changes in (i.e., declining) body mass index (BMI), and worsening
scores on measures of eating disorder symptoms and general mental
health during treatment compared to the “not terminal” groups, the “ter-
minal” specifier may be warranted. Alternatively, if these “terminal”
groups show considerable in-group variability and little or no evidence
of deterioration, the “terminal” specifier may not be warranted.
Method
In total, 782 participants (T-AN: 4.9%, n = 51) were included in this
retrospective cohort study from July 2020 to June 2023. The eating dis-
order clinics were located in Denver, Colorado, and Dallas, Texas in
the United States. Due to the clinical nature of this study, discharge
data varies (cf., Tables 1 and 2); the level of missing data is notable,
and reasonably in line with our expectations due to the time-pressed
nature of clinical activity in these settings in general and of dis-
charges in particular (i.e., U.S. insurance payer constraints and
patient preferences).1 These facilities predominantly provide inpa-
tient (24/7 care with intensive medical assistance and stabilization),
residential (24/7 care with less intensive medical assistance), partial
hospitalization program (7 days/week treatment), intensive outpa-
tient (3–5 days/week treatment), and virtual intensive outpatient
(3–6 hr/day, 3–5 days/week treatment) levels of care. Each adult partic-
ipant provided informed consent before completing an online self-report
assessment within 5 days of admission and again within 7 days of dis-
charge. The study was approved by the Salus Institutional Review
Board. This study was not preregistered. Measures and coding are avail-
able by contacting the corresponding author. Data are not available
since some information was gathered from patient medical records
and participants did not consent to publicly share deidentified data.
Measures
The Semistructured Clinical Interview Based on DSM-5
Criteria
The tool assesses for the presence or absence of psychiatric disor-
ders (APA, 2013). Masters-level clinical assessment specialists, who
were either licensed or working toward licensure, administered the eat-
ing disorder modules prior to any other study participation, via a phone
287
interview. To ensure interviewer fidelity, masters-level clinical assess-
ment managers completed random quality audits on a sample of com-
pleted assessment documentation. Furthermore, physicians continually
evaluated and approved the diagnoses of the participants throughout
treatment. Importantly, Criterion A requires a significantly low body
weight. The DSM-5 acknowledges familial and other sources (e.g.,
physicians) may aid in evaluating the history of weight loss and
other features of AN, as it is rare for the individual to endorse criterion
A or have accurate insight (APA, 2013, p. 340). As some of the partic-
ipants in both the T-AN and NT-AN groups had BMIs above the
World Health Organization cutoffs (i.e., 18.5 kg/m2; APA, 2013),
we would like to note that all/the vast majority of our sample had
threshold AN at some point in the fairly recent past, and either: (a)
still had it at admission; or (b) did not quite meet full criteria at admis-
sion but were symptomatic enough to be admitted to an inpatient facil-
ity because of AN symptoms (i.e., they are still struggling with the AN
syndrome if not full-criteria AN).2
Biological Samples
As noted in the introduction, objective measures of terminality are
observed in other illnesses (e.g., end-stage cancer, HIV, etc.) near
death. Due to the definition of “terminal,” one would anticipate similar
biological changes among those in the T-AN group. Therefore, blood
samples were collected to obtain white blood cell counts (WBC), albu-
min levels, and AST levels at admission and discharge. Only albumin
and AST results are included in final analyses as WBC for the terminal
sample at discharge was limited (n = 9; see Footnote 3). Healthy
ranges, according to the facilities that analyzed the samples, are
3.4–10.8 for WBC, 3.8–5.0 for albumin levels, and 0–40 for AST lev-
els (Laboratory Corporation of America, 2021a, 2021b; Quest
Diagnostics, 2019). Albumin levels below healthy ranges may indi-
cate infection, inflammation, kidney disease, liver disease, or poor
nutrition, and levels above healthy ranges may indicate dehydration
or severe diarrhea (The Cleveland Clinic, 2022a). WBC levels
below healthy ranges may indicate a vulnerability toward developing
infections (The Cleveland Clinic, 2022c), and levels above healthy
ranges may indicate infection, inflammation, injury, and immune sys-
tem disorders (The Cleveland Clinic, 2022b). AST levels below
healthy ranges are generally less medically important, whereas levels
above healthy ranges may indicate chronic hepatitis; heart, kidney,
bone, or muscle damage; liver cancers; or cirrhosis (Ramirez &
Fletcher, 2023). Notably, AST levels can elevate during immediate
periods of refeeding (Ozawa et al., 1998); however, as these levels
were measured at admission and discharge (times when the immediate
effects of refeeding are not relevant), it is improbable that refeeding
influenced our results.
1
It is important to acknowledge that participants who complete admission
and discharge assessments may not be representative of those with only
admission data. Past analyses on a related sample indicated attrition had no
influence on outcomes (Joiner et al., 2022), and analyses on this sample fur-
ther affirmed that view.
2
To ensure there were no substantive differences between the T-AN group
above versus below 18.5 kg/m2, we reran all analyses further classifying the
T-AN group into two categories: BMI above 18.5 kg/m2 and BMI below
18.5 kg/m2. There were no meaningful differences between the two T-AN
BMI categories except for the EDE-Q-weight subscale. When further exam-
ined, almost everyone in the T-AN group (i.e., except for one participant in
the above BMI category who showed no change) improved from admission
to discharge.
 288 ROBISON ET AL.

Table 1
Sample Characteristics
Terminal (n = 51) Not terminal (all; n = 731) Not terminal (30 and over; n = 133)
Group demographics n Range M (SD) n Range M (SD) n Range M (SD)
Age 51 30–61 42.65 (10.21) 731 18–65 25.15 (9.08) 133 30–65 41.45 (9.18)
Days admitted 51 6–278 70.92 (51.33) 731 1–366 78.22 (53.57) 133 2–366 77.56 (52.60)
Diagnosis % % %
AN-R 39 76.5 496 67.8 84 63.2
AN-BP 11 21.6 235 32.1 49 36.8
Level of care % % %
Inpatient 19 37.3 232 31.7 64 48.1
Residential 18 35.3 288 39.4 40 30.1
Partial hospitalization 10 19.6 146 20.0 18 13.5
Intensive outpatient 2 3.9 7 1.0 0
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Intensive virtual outpatient 2 3.9 58 7.9 11 8.3

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Gender % % %
Female 48 94.1 616 84.3 115 86.5
Male 1 2.0 41 5.6 7 5.3
Nonbinary 1 2.0 27 3.7 4 3.0
Transgender 0 19 2.6 0
Denied response 1 2.0 28 3.8 2 1.5
Race % % %
Caucasian 47 92.2 593 81.8 114 85.7
Black/African American 1 2.0 13 1.8 1 0.8
Hispanic or Latino 1 2.0 33 4.5 1 0.8
Asian 0 21 2.9 3 2.3
American Indian/Native American 0 3 0.4 0
Native Hawaiian/Pacific Islander 0 2 0.3 1 0.8
Multiracial 1 2.0 17 7 3 2.3
Unknown 1 2.0 49 6.7 1 0.8
Note. AN-R = anorexia nervosa-restricting subtype; AN-BP = anorexia nervosa-binge-purge subtype.

BMI yourself”) features death ideation as much as or more than it does

BMI was used as a physiological indicator of improvement. In this
study, we compared BMI at admission to BMI at discharge as a
measure of standardized alteration in weight change accounting
for height. As a cardinal diagnostic criterion for AN involves signifi-
cantly low body weight, BMI was the most appropriate weight-
related measurement construct (APA, 2013). Please see the
Semi-Structured Clinical Interview based on DSM-5 criteria for
additional information on the BMI within this sample.
Patient Health Questionnaire–9 (PHQ-9)
The PHQ-9 is a self-report tool for assessment of the severity of
depressive symptoms directly relating to the DSM-IV criteria for
major depressive disorder (Kroenke & Spitzer, 2002; Kroenke et
al., 2001; Spitzer et al., 2014). The questionnaire assesses a respon-
dent’s preceding 2 weeks, asking how often participants had been
bothered by problems such as: “little interest or pleasure in doing
things.” Items were scored on a Likert scale ranging from 0 = not
at all to 3 = nearly every day. Total scores are summed, ranging
from 0 to 27. The PHQ-9 had good reliability at admission
(α = .90) and at discharge (α = .91). Importantly, Item 9 of the
PHQ-9 assesses desire for death asking: “Thoughts that you would
be better off dead, or thoughts of hurting yourself in some way?”
Due to the content of this item (i.e., “death” with no specificity
toward suicide), it is defensible as an index of death ideation.
Further to this point, is notable that the stem phrase of this item
(i.e., “thoughts that you would be better off dead, or of hurting
suicidality, in that it both leads with death ideation per se and devotes
more words to death ideation than to suicidality.
This single item was used as a proxy for Gaudiani et al.’s (2022)
fourth criterion for T-AN. The PHQ-9 is a well-validated measure
(Kroenke & Spitzer, 2002; Kroenke et al., 2001; Spitzer et al.,
2014), and regarding the one-item index of death ideation, there is
evidence that such measures are defensibly reliable and valid (e.g.,
Joiner et al., 2022; Robison et al., 2022).
Generalized Anxiety Disorder–7 (GAD-7)
The GAD-7 is a self-report tool for assessment of the severity
of anxiety symptoms relating to the DSM-IV for generalized anx-
iety disorder (Dhira et al., 2021; Spitzer et al., 2006). The ques-
tionnaire assesses a respondent’s preceding 2 weeks, asking how
often participants had been bothered by problems such as: “not
being able to stop or control worrying.” Items were scored on
a Likert scale ranging from 0 = not at all to 3 = nearly every
day. Total scores are summed, ranging from 0 to 21. The
GAD-7 is a well-validated measure (Dhira et al., 2021; Spitzer
et al., 2006) with good reliability at admission (α = .89) and at
discharge (α = .92) in these data.
Obsessive-Compulsive Inventory–Revised (OCI-R)
The OCI-R is a 15-item self-report tool evaluating six different
aspects of OCD symptoms: washing, checking, ordering, obsessing,
neutralizing, and hoarding. The OCI-R response format ranges from
 TERMINAL ANOREXIA NERVOSA 289

Table 2
Descriptive Statistics
Terminal (n = 51) Not terminal (all; n = 731) Not terminal (30 and over; n = 133)
Group
Variable n Range M (SD) n Range M (SD) n Range M (SD)
Albumin-A 45 3.3–5.5 4.45 (0.58) 108 3.3–5.5 4.56 (0.42) 60 3.3–5.5 4.50 (0.43)
Albumin-D 29 3.7–5.0 4.49 (0.32) 88 3.4–5.1 4.41 (0.35) 45 3.4–5.1 4.39 (0.40)
AST-A 40 12–289 46.30 (61.65) 102 12–321 32.48 (47.85) 56 12–321 38.37 (58.79)
AST-D 29 9–63 24.66 (10.40) 87 9–63 23.45 (9.98) 45 9–63 26.05 (9.92)
BMI-A 51 11.3–33.2 18.41 (4.5) 731 11.2–39.8 18.38 (3.28) 133 11.4–30.8 17.90 (3.36)
BMI-D 51 11.7–35.1 20.79 (4.22) 731 13.0–39.9 21.23 (3.00) 133 15.5–35.9 21.18 (3.05)
PHQ-9-A 45 0–27 16.24 (6.98) 691 0–27 16.18 (7.03) 116 0–27 14.28 (7.53)
PHQ-9-D 44 0–26 12.57 (8.22) 626 0–27 10.22 (6.95) 119 0–25 8.28 (7.08)
GAD-7-A 42 0–21 13.81 (6.18) 424 0–21 13.81 (5.51) 76 0–21 12.62 (6.05)
GAD-7-D 41 0–21 10.73 (6.64) 436 0–21 10.11 (6.02) 83 0–21 8.67 (6.39)
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OCI-R-A 44 0–60 23.50 (16.79) 687 0–72 21.76 (15.92) 116 0–65 17.94 (14.45)
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OCI-R-D 45 0–54 17.60 (15.69) 623 0–65 17.14 (14.81) 120 0–60 13.13 (13.05)
EDE-Q-G-A 45 0–5.8 3.88 (1.84) 694 0–6 3.86 (1.56) 115 0.05–5.9 3.45 (1.71)
EDE-Q-G-D 45 0–6 2.75 (1.72) 628 0–5.6 2.33 (1.41) 120 0–5.1 2.19 (1.38)
EDE-Q-E-A 45 0–6 3.12 (1.67) 695 0–6 3.17 (1.57) 115 0–6 2.73 (1.77)
EDE-Q-E-D 45 0–6 2.03 (1.64) 628 0–5.2 1.63 (1.28) 120 0–4.4 1.41 (1.24)
EDE-Q-R-A 45 0–6 3.77 (2.33) 696 0–6 3.65 (1.97) 116 0–6 3.29 (2.14)
EDE-Q-R-D 45 0–6 1.75 (1.92) 630 0–6 1.14 (1.35) 121 0–5.8 1.00 (1.33)
EDE-Q-S-A 45 0–6 4.49 (1.94) 694 0–6 4.50 (1.62) 115 0–6 4.09 (1.80)
EDE-Q-S-D 45 0–6 3.83 (1.98) 628 0–6 3.57 (1.84) 120 0–6 3.49 (1.88)
EDE-Q-W-A 45 0–6 4.14 (1.88) 694 0–6 4.12 (1.70) 115 0–6 3.70 (1.83)
EDE-Q-W-D 45 0–6 3.40 (2.01) 628 0–6 2.97 (1.82) 120 0–6 2.85 (1.82)
Note. AST = aspartate aminotransferase; BMI = body mass index; PHQ-9 = Patient Health Questionnaire–9; GAD-7 = Generalized Anxiety Disorder–7;
OCI-R = Obsessive-Compulsive Inventory–Revised; EDE-Q = Eating Disorder Examination Questionnaire; A = admission; D = discharge; G = global;
E = eat concern; R = restraint; S = shape; W = weight.

0 = not at all to 4 = extremely. For the purposes of this study, the
scale was scored by summing all questions into one total score.
The measure has adequate reliability and validity (Huppert et al.,
2007). These data did not include item-level OCI-R scores, preclud-
ing internal consistency reliability analysis; however, the test–retest
reliability was substantial (r = .76; p , .001).
Eating Disorder Examination–Questionnaire (EDE-Q)
The EDE-Q is a 28-item self-report tool evaluating four different
aspects of disordered eating: eating concern, restraint, shape con-
cern, and weight concern (Berg et al., 2012; Rose et al., 2013).
The EDE-Q response format ranges from 0 = no days to 6 = every
day. For the purposes of this study, both the Global scale (an average
of the four subscales) and the four distinct subscales were scored and
used independently. The EDE-Q is a reasonably well-validated mea-
sure (Berg et al., 2012; Rose et al., 2013) and had excellent reliability
at admission (α = .98) and at discharge (α = .99).
Analytic Plan
Descriptive Statistics and Group Heterogeneity
We analyzed and compared the descriptive statistics of the T-AN
group (e.g., standard deviations; see Table 2) at admission and dis-
charge to the “not terminal” group (i.e., NT-AN) and to the “not ter-
minal” subset, aged 30 and over (i.e., NTO-AN). To assess for
differences in within-group heterogeneity, we tested standard devia-
tion differences, using F tests (see Table 3; Snedecor & Cochran,
1982). Using a proxy for the fourth criterion presented by
Gaudiani et al. (2022, p. 1), “a clear and consistent determination
by a patient who possesses decision-making capacity that additional
treatment would be futile, knowing their actions will be fatal,” a
T-AN subset (TD-AN; n = 16) who endorsed some desire for
death on the PHQ-9, answering “several days” or more, was also
compared to both NT-AN and the NTO-AN subset (see the online
supplemental materials). Due to the high number of statistical
tests, the Benjamini–Hochberg procedure was employed to control
the familywise error rate (i.e., the chances of Type-I error), adjusting
the p-value threshold to p , .01 (Benjamini & Hochberg, 1995).
This p value was used for the remainder of analyses for ease of inter-
pretation and consistency across comparisons.
Treatment Response
Next, to assess change over time, we calculated the percentage
of the T-AN group that did not improve on physiological or self-
report measures from admission to discharge, comparing them to
both NT-AN and the NTO-AN subsets. Chi-square difference
tests were conducted to assess if these differences in improve-
ment were statistically significant. Analyses were repeated com-
paring those in the TD-AN subset to both NT-AN and the
NTO-AN subsets.
We then conducted regression analyses to compare terminal group
status and admission scores to predict discharge scores. The groups
were coded NT-AN = 0 and T-AN = 1, with all regression analyses
predicting discharge outcomes from admission scores and group sta-
tus (“terminal” vs. not; see Table 4). Eleven models were run involv-
ing the entire sample (i.e., comparing T-AN to NT-AN), one for each
of 11 clinical predictors/outcomes: albumin, AST, BMI, PHQ-9,
GAD-7, OCI-R, EDE-Q-global, EDE-Q-eating concern, EDE-Q-
restraint, EDE-Q-shape concern, and EDE-Q-weight concern.
 290 ROBISON ET AL.

Table 3
F tests
Terminal and not terminal (all) Terminal and not terminal (30 and over)
Variable p F Effect p F Effect
Albumin-A .007** 1.91 1.91 .021* 1.82 1.82
Albumin-D .604 0.84 1.20 .623 0.64 1.56
AST-A .046* 1.66 1.66 .736 1.10 1.10
AST-D .748 1.09 1.09 .764 1.10 1.10
BMI-A ,.001*** 1.88 1.88 ,.001*** 1.79 1.79
BMI-D ,.001*** 1.98 1.98 .004** 1.91 1.91
PHQ-9-A .999 0.99 1.01 .576 0.86 1.16
PHQ-9-D .100 1.40 1.40 .213 1.35 1.35
GAD-7-A .278 1.26 1.26 .856 1.04 1.04
GAD-7-D .355 1.22 1.22 .754 1.08 1.08
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OCI-R-A .581 1.11 1.11 .212 1.35 1.35

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OCI-R-D .552 1.12 1.12 .121 1.45 1.45

EDE-Q-G-A .104 1.42 1.42 .496 1.18 1.18
EDE-Q-G-D .028* 1.63 1.63 .034* 1.75 1.75
EDE-Q-E-A .525 1.31 1.31 .674 0.89 1.23
EDE-Q-E-D .013* 1.64 1.64 .018* 1.75 1.75
EDE-Q-R-A .096 1.40 1.40 .470 1.19 1.19
EDE-Q-R-D ,.001*** 2.02 2.02 .002** 2.08 2.08
EDE-Q-S-A .073 1.43 1.43 .523 1.16 1.16
EDE-Q-S-D .458 1.16 1.16 .648 1.11 1.11
EDE-Q-W-A .314 1.22 1.22 .801 1.06 1.06
EDE-Q-W-D .322 1.22 1.22 .399 1.22 1.22
Note. AST = aspartate aminotransferase; BMI = body mass index; PHQ-9 = Patient Health Questionnaire–9;
GAD-7 = Generalized Anxiety Disorder–7; OCI-R = Obsessive-Compulsive Inventory–Revised; EDE-Q =
Eating Disorder Examination Questionnaire; A = admission; D = discharge; G = global; E = eat concern;
R = restraint; S = shape; W = weight.
* p , .05. ** p , .01. *** p , .001.

Each model was structured as follows: group status (T-AN vs.
NT-AN) and clinical predictor at admission predicting the clinical
predictor at discharge (see Table 3a–k). Eleven more identical anal-
yses were run comparing the T-AN group to the NTO-AN subset
(see Table 3l–v). Results were reanalyzed comparing those in the
TD-AN subset to both the NT-AN group and the NTO-AN subset
(see the online supplemental materials). All regression analyses
(i.e., admission scores to predict discharge scores) were additionally
analyzed by each group and subset, respectively to compare the stan-
dardized regression coefficients across all groups and subsets (see
the online supplemental materials).
Sensitivity
Finally, to assess statistical sensitivity, all analyses were reana-
lyzed using 10 random subsamples with identical sample sizes to
robustly account for any patterns of missing data and to assess the
consistency of our results. As an example, we randomly selected
10 subsamples of 51 participants from the NT-AN group and 10 sub-
samples of 51 participants from the NTO-AN subset to compare to
the T-AN group, respectively. Results were reanalyzed comparing
those in the TD-AN subset to both the NT-AN group and the
NTO-AN subset. Additionally, we also compared the averaged var-
iances of the 10 random subsamples to the variance of the T-AN
group and the TD-AN subset, respectively.
Transparency and Openness
Data are not publicly available (i.e., data involve medical health
records, and participants did not consent to de-identified public data
sharing), but code and output are accessible through the online supple-
mental materials. Hypotheses and analyses were not preregistered.
Results
Descriptive Statistics
See Table 1 for demographic statistics of the T-AN group, the
NT-AN group, and the NTO-AN subset (see the online supple-
mental materials for the TD-AN subset demographic and descrip-
tive statistics). The T-AN group was not significantly different
from the NT-AN group regarding the frequencies of diagnostic
subtype (i.e., AN-restricting type and AN-binge-eating/purging
type), gender, race, or levels of care. The T-AN group was stat-
istically significantly different from the NT-AN group regarding
average age, t(827) = 13.59, p , .001; Cohen’s d = 1.83.3 The
T-AN group was not statistically significantly different from
the NT-AN group regarding BMI at admission, t(780) = 0.05,
p = .957; Cohen’s d = 0.01, nor at discharge, t(780) = 0.99,
p = .324; Cohen’s d = 0.12; see Figure 1. Please see Table 1
for a full list of descriptive statistics regarding the sample
3
A latent class analysis was conducted to further assess if the binary asso-
ciations related to the terminal criteria (i.e., AN type, age of 30 and over, read-
mittance to high-quality care, and endorsement of desire for death) identified
a group presenting as “terminal.” Two-, three-, and four-class solutions were
analyzed with different indices supporting different class solutions. The two-
class solution did not support a “terminal” distinction because the model fit
was very poor, the distinction between the classes was minimal (i.e., low
entropy = 0.52), and the classes were based entirely on the readmission
variable.
 TERMINAL ANOREXIA NERVOSA 291

Table 4
Multiple Regression Models
Outcome
Model Predictor moderator β SE 95% CI t p sr 2
a (n = 116; R 2 = .121) Albumin-D
Albumin-A .34 0.09 [0.16, 0.51] 3.81 ,.001** .113
Terminality .11 0.09 [−0.06, 0.29] 1.25 .215 .012
b (n = 112; R 2 = .016) AST-D
AST-A .11 0.10 [−0.08, 0.30] 1.18 .241 .013
Terminality .04 0.10 [−0.15, 0.23] 0.39 .695 .004
c (n = 782; R = .545)
2
BMI-D
BMI-A .74 0.02 [0.69, 0.79] 30.53 ,.001** .544
Terminality −.04 0.02 [−0.08, 0.01] −1.52 .129 .001
d (n = 590; R 2 = .308) PHQ-9-D
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PHQ-9-A .55 0.03 [0.48, 0.62] 15.99 ,.001** .301

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Terminality .08 0.03 [0.01, 0.14] 2.22 .027* .006

e (n = 377; R 2 = .270) GAD-7-D
GAD-7-A .52 0.04 [0.43, 0.61] 11.73 ,.001** .268
Terminality .04 0.04 [−0.05, 0.13] 0.87 .384 .001
f (n = 584; R 2 = .579) OCI-R-D
OCI-R-A .76 0.03 [0.71, 0.81] 28.26 ,.001** .579
Terminality .00 0.03 [−0.05, 0.06] 0.09 .926 .000
g (n = 440; R = .298)
2
EDE-Q-G-D
EDE-Q-G-A .54 0.04 [0.46, 0.62] 13.48 ,.001** .292
Terminality .08 0.04 [0.00, 0.16] 2.01 .045* .007
h (n = 594; R 2 = .208) EDE-Q-E-D
EDE-Q-E-A .45 0.04 [0.38, 0.52] 12.23 ,.001** .201
Terminality .09 0.04 [0.02, 0.17] 2.56 .011* .009
i (n = 596; R 2 = .114) EDE-Q-R-D
EDE-Q-R-A .31 0.04 [0.24, 0.39] 8.07 ,.001** .097
Terminality .13 0.04 [0.05, 0.21] 3.38 ,.001** .017
j (n = 594; R 2 = .330) EDE-Q-S-D
EDE-Q-S-A .57 0.03 [0.51, 0.64] 17.04 ,.001** .326
Terminality .04 0.03 [−0.02, 0.11] 1.25 .212 .002
k (n = 594; R = .330)
2
EDE-Q-W-D
EDE-Q-W-A .57 0.03 [0.51, 0.64] 16.97 ,.001** .327
Terminality .06 0.03 [−0.01, 0.13] 1.80 .072 .004
l (n = 74; R 2 = .123) Albumin-D
Albumin-A .33 0.11 [0.11, 0.55] 2.94 .004** .107
Terminality .13 0.11 [−0.10, 0.35] 1.13 .264 .016
m (n = 71; R 2 = .017) AST-D
AST-A .12 0.12 [−0.13, 0.36] 0.95 .344 .013
Terminality −.08 0.12 [−0.32, 0.17] −0.63 .528 .006
n (n = 184; R 2 = .640) BMI-D
BMI-A 80 0.04 [0.71, 0.89] 17.91 ,.001** .638
Terminality −.10 0.04 [−0.19, −0.01] −2.26 .025* .010
o (n = 143; R = .371)
2
PHQ-9-D
PHQ-9-A .56 0.07 [0.43, 0.69] 8.29 ,.001** .309
Terminality .18 0.07 [0.05, 0.31] 2.65 .009** .032
p (n = 102; R 2 = .335) GAD-7-D
GAD-7-A .56 0.08 [0.40, 0.72] 6.81 ,.001** .312
Terminality .10 0.08 [−0.06, 0.26] 1.22 .224 .010
q (n = 143; R 2 = .574) OCI-R-D
OCI-R-A .74 0.06 [0.63, 0.86] 13.33 ,.001** .541
Terminality .06 0.06 [−0.05, 0.17] 1.15 .250 .004
r (n = 118; R 2 = .432) EDE-Q-G-D
EDE-Q-G-A .63 0.07 [0.49, 0.77] 8.99 ,.001** .400
Terminality .13 0.07 [−0.01, 0.27] 1.83 .070 .017
s (n = 145; R = .328)
2
EDE-Q-E-D
EDE-Q-E-A .54 0.07 [0.40, 0.67] 7.77 ,.001** .286
Terminality .17 0.07 [0.03, 0.31] 2.47 .015* .029
t (n = 146; R 2 = .179) EDE-Q-R-D
EDE-Q-R-A .34 0.08 [0.19, 0.49] 4.42 ,.001** .112
Terminality .24 0.08 [0.09, 0.39] 3.15 .002* .057
u (n = 145; R 2 = .483) EDE-Q-S-D
EDE-Q-S-A .69 0.06 [0.57, 0.81] 11.45 ,.001** .478
Terminality .03 0.06 [−0.08, 0.15] 0.58 .556 .001
(table continues)
 292
Table 4 (continued)
Model Predictor moderator β SE
v (n = 145; R 2 = .447) EDE-Q-W-D
EDE-Q-W-A .66
Terminality .09
Note. Models a–k include not terminal (all); Models l–v include not terminal (30 and over). Terminality = −0.5 was not terminal, 0.5 was terminal. CI =
confidence interval; AST = aspartate aminotransferase; BMI = body mass index; PHQ-9 = Patient Health Questionnaire–9; GAD-7 = Generalized Anxiety
Disorder–7; OCI-R = Obsessive-Compulsive Inventory–Revised; EDE-Q = Eating Disorder Examination Questionnaire; A = admission; D = discharge;
G = global; E = eat concern; R = restraint; S = shape; W = weight.
* p , .05. ** p , .01.
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separated by group status (i.e., T-AN, NT-AN, and NTO-AN; see
This document is copyrighted by the American Psychological Association or one of its allied publishers.
the online supplemental materials for the TD-AN subset descrip-
tive statistics).4
Group Heterogeneity
F tests were conducted on standard deviations (see Table 2) on
both admission and discharge scores of all study variables (see
Table 3).5 The standard deviations for the T-AN group and the
T-AN subset endorsing desire for death (TD-AN; see the online sup-
plemental materials), compared to the NT-AN group and the NT-AN
subset 30 years or older (NTO-AN), were generally similar, and if
anything, larger in T-AN group and the TD-AN subset.
The T-AN group (compared to NT-AN) had statistically signifi-
cantly larger standard deviations on Albumin levels at admission,
BMI at admission and discharge, and EDE-Q Restraint at discharge
(p , .01). The T-AN group (compared to the NTO-AN subset) had
statistically significantly larger standard deviations on BMI at admis-
sion, BMI at discharge, and EDE-Q restraint at discharge (ps , .01).
The TD-AN subset was then compared to the NT-AN group and
NTO-AN subset. The TD-AN subset had statistically significantly
lower standard deviations than the NT-AN group (p , .01) and
NTO-AN subset (p , .01) on AST at admission; however, all partic-
ipants fell within normal ranges. The TD-AN subset had statistically
significantly higher standard deviations than the NTO-AN subset on
BMI at admission (p , .01).
Treatment Response
We then identified, by group (e.g., the T-AN group compared to
the NT-AN group), individuals who did not show improvement
from admission to discharge on biological measures, BMI, and all
self-report measures. Regarding biological parameters, the T-AN
group had one participant (in the TD-AN subset) out of 29 (3.4%)
discharge with Albumin levels slightly below healthy ranges. The
NT-AN group had eight participants (five in the NTO-AN subset)
discharge with Albumin levels slightly below healthy ranges
(NT-AN: eight out of 88 [9.1%]; NTO-AN subset: five out of 45
[11.1%]). The T-AN group and the NT-AN group percentages
were not statistically significantly different from one another
(χ2 = 0.98, p = .323, wc = .09), and remained nonsignificant when
comparing the T-AN group to the NTO-AN subset (χ2 = 1.39,
p = .238, wc = .14). One participant in the TD-AN subset dis-
charged with serum levels of albumin slightly below healthy ranges;
chi-square difference tests between the TD-AN subset and the
NT-AN group were not statistically significant (χ2 = 0.04,
ROBISON ET AL.
Outcome
95% CI t p sr 2
0.06 [0.53, 0.78] 10.52 ,.001** .431
0.06 [−0.04, 0.21] 1.37 .174 .007
p = .842, wc = .02), and remained nonsignificant when comparing
the TD-AN subset and the NTO-AN subset (χ2 = 0.50, p = .478,
wc = .10).
The T-AN group had two out of 29 (6.9%) discharge with AST
levels slightly above the healthy range. The NT-AN group had six
participants discharge with slightly elevated AST levels (NT-AN:
six out of 87 [6.9%]; NTO-AN subset: four out of 45 [8.9%]).
The chi-square difference test between the T-AN and NT-AN groups
was not statistically significant (χ2 = 0.00, p = 1.00, wc = 0), and
remained nonsignificant when comparing the T-AN group and the
NTO-AN subset (χ2 = 0.09, p = .759, wc = .04). Every participant
in the TD-AN subset (i.e., endorsing a desire for death) discharged
with healthy ranges of AST; chi-square difference tests between the
TD-AN subset and the NT-AN group were not statistically signifi-
cant (χ2 = 0.66, p = .416, wc = .08), and remained nonsignificant
when comparing the TD-AN subset and the NTO-AN subset
(χ2 = 0.86, p = .353, wc = .13).
When comparing both BMI and across all self-report measures
(e.g., PHQ-9, GAD-7, OCI-R, and EDE-Q) zero out of 51 (0%) of
the T-AN group worsened regarding both BMI and across all self-
report measures; these results were identical for the NT-AN group
(NT-AN: zero out of 321 [0%]; NTO-AN subset: zero out of 68
[0%]). In T-AN, one out of 51 (2.0%) worsened on all self-report
measures independent of BMI. The NT-AN group had lower per-
centages of participants who worsened across all self-report mea-
sures (NT-AN: three out of 321 [0.93%]; NTO-AN subset: zero
out of 68 [0%]). Chi-square difference tests between the T-AN
and NT-AN groups, however, indicate no statistically significant dif-
ference between them (χ2 = 0.44, p = .509, wc = .04), and remained
non-significant when comparing the T-AN group and the NTO-AN
subset (χ2 = 1.35, p = .246, wc = .11). Every participant in the
TD-AN subset (i.e., endorsing a desire for death) improved on
4
Eight participants in the T-AN group (15.7%) had an involuntary admis-
sion at some point during their treatment (two of whom were in the TD-AN
subset); only one participant of the eight did not improve on the EDE-Q mea-
sures (while improving on all other measures) during their stay. Furthermore,
everyone in the TD-AN subset showed improvement. We randomly selected
60 participants in the NT-AN group (30 of whom were NTO-AN), three of
whom had involuntary visits (5.0%). The three participants were all over
30 years old. Chi-square difference tests between T-AN and NT-AN were
not statistically significant (χ2 = 3.53, p = .060) and remained non-
significant when comparing T-AN to NTO-AN (χ2 = 0.77, p = .382).
5
Only AST and albumin results (not WBC counts) are included in the final
analyses presented. WBC was collected at admission, with an n = 9 at dis-
charge for the terminal sample, precluding full inclusion. Nevertheless, for
those nine patients, WBC looked unremarkable.
 TERMINAL ANOREXIA NERVOSA
Figure 1
BMI Admission to Discharge by Group
BMI Admission to Discharge
22.00
21.00
20.00
19.00
18.00
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
17.00
16.00
Admission
Note. BMI = body mass index; T-AN = terminal anorexia nervosa; NT-AN = not terminal anorexia nervosa;
TD-AN = T-AN—and a smaller subset who also met a proxy index of the fourth criterion involving death;
NTO-AN = to a “not terminal” subset 30 years of age or older. See the online article for the color version of
this figure.
both BMI and across all self-report measures; chi-square difference
tests comparing the percentages of participants who worsened across
all self-report measures (independent of BMI) between the TD-AN
subset and the NT-AN group were not statistically significant
(χ2 = 0.15, p = .698, wc = .02).
Finally, we compared the groups and subsets exclusively on the
EDE-Q subscales. In the T-AN group, four of 51 (7.8%) worsened
only on EDE-Q subscales. In the NT-AN group, a lower percentage
of participants worsened only on EDE-Q subscales (NT-AN: 19 of
403 [4.7%]; NTO-AN subset: five of 93 [5.4%]). Chi-square differ-
ence tests between T-AN and NT-AN, however, were not statisti-
cally significant (χ2 = 0.92, p = .337, wc = .04), and remained
nonsignificant when comparing T-AN to NTO-AN (χ2 = 0.34,
p = .557, wc = .04). Every participant in the TD-AN subset
improved across all EDE-Q related measures; chi-square difference
tests between the TD-AN subset and the NT-AN group were not stat-
istically significant (χ2 = 0.79, p = .374, wc = .04), and remained
non-significant when comparing the TD-AN subset and the
NTO-AN subset (χ2 = 0.90, p = .342, wc = .09).
Terminal Group Status and Admission Scores to Predict
Discharge
Next, multiple regression analyses tested the effect that “terminal”
group status had on admission to discharge scores (T-AN compared
to both NT-AN and NTO-AN; see Table 3). Group status (i.e., T-AN
compared to NT-AN) was statistically significantly predictive of
EDE-Q-Restraint at discharge (p , .01 level; β = .13, SE = 0.04,
p , .001, sr 2 = .017) such that the T-AN group reported higher lev-
els of restraint concerns at discharge, controlling for scores at admis-
sion. When the T-AN group was compared to NTO-AN, group status
was statistically significantly predictive of PHQ-9 at discharge
(β = .18, SE = 0.07, p = .009, sr 2 = .032) and EDE-Q-restraint at
discharge (β = .24, SE = 0.08, p = .002, sr 2 = .057) such that the
T-AN group reported higher PHQ-9 and EDE-Q-restraint scores at
293
T-AN
TD-AN
NT-AN
NTO-AN
Discharge
discharge, controlling for their respective scores at admission.
Similar results emerged when comparing the TD-AN subset to the
NT-AN group and the NTO-AN subset. Group status was statisti-
cally significantly predictive of EDE-Q-restraint at discharge when
comparing the TD-AN subset to the NT-AN group (p , .01 level;
β = .13, SE = 0.04, p = .002, sr 2 = .016) and remained significant
when comparing the NT-AN subset to the NTO-AN subset
(β = .28, SE = 0.09, p = .002, sr 2 = .076). In both instances, the
TD-AN subset reported higher EDE-Q-restraint scores at discharge,
controlling for their respective scores at admission.
Regression analyses independently examined by each group and
subset indicated fairly similar standardized regression coefficients
and overlapping confidence intervals (see the online supplemental
materials).
Sensitivity
Finally, all results were reanalyzed comparing the T-AN group to
10 random subsamples of the NT-AN group (n’s = 51) and to 10
simple random subsamples of the NTO-AN subset (n’s = 51).
Additionally, the TD-AN subset was compared to 10 simple random
subsamples of the NT-AN group (n’s = 16) and to 10 random sub-
samples of the NTO-AN subset (n’s = 16). In total, 1,800 analyses
were conducted (i.e., 45 analyses per subsample, replicated 10 times
across four comparison groups). We also compared the averaged var-
iances of the 10 random subsamples to the variance of the T-AN
group and the TD-AN subset, respectively. These analyses affirm
the results and conclusions of the main analyses (i.e., the averaged
variances were overwhelmingly nonsignificant and when signifi-
cant, the T-AN group and TD-AN subset had higher variability).
Age was the only consistently significantly different parameter
between the T-AN group/TD-AN subsets and the NT-AN subsam-
ples. This finding can be viewed as validity check on our analyses
as age differences are built into the criteria for “terminality.”
Otherwise (i.e., independent of the finding regarding expected age
 294 ROBISON ET AL.
differences) of the 1,760 analyses conducted not involving age,
1,743 did not support the concept of T-AN (i.e., over 99% were non-
significant or against the concept of “terminal”). Put differently, 17
analyses of the 1,760 not involving age accorded with the T-AN con-
cept (0.97%). As the p value was set to .01, it is reasonable to expect
one in 100 significant findings to be attributable to chance alone.
The only conceivable solace in these findings for supporters of the
T-AN concept was that of the 17 significant results, six which
involved higher mean levels of EDE-Q-restraint concerns at dis-
charge among the T-AN group in the regression analyses.
However, these six significant findings out of 40 analyses on
EDE-Q-restraint concerns (i.e., 10 subsamples across four groups),
are outweighed by the 34 which did not support the T-AN position.
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Discussion
The aims of this study were to compare the heterogeneity and treat-
ment responses of a clinical sample categorized as T-AN, using three
of the four criteria that Gaudiani et al. (2022) proposed for T-AN—
and a smaller subset who also met a proxy index for the fourth
criterion—to a “not terminal” group and a smaller subset 30 years
of age or older. The T-AN group, compared to the NT-AN group
and NTO-AN subset, displayed similar means, with generally
equal or higher variability on physiological and self-report measures.
Additionally, the TD-AN subset, compared to the NT-AN group and
NTO-AN subset, also displayed similar means with generally higher
variability. All statistically significant differences indicated that the
T-AN group had higher variability compared to NT-AN group and
NTO-AN subset (though the TD-AN subset had statistically signifi-
cant smaller variability in the AST at admission), indicating generally
equivalent patterns of heterogeneity for “terminal” and “not termi-
nal” groups, at odds with the concept of terminality.
Regarding improvement, all groups, including T-AN and the
TD-AN subset, mostly showed significant improvement from admis-
sion to discharge across all measures. The T-AN group showed
higher percentages of participants with a higher percentage of partic-
ipants who worsened on all self-report measures (i.e., PHQ-9,
GAD-7, OCI-R, and EDE-Q), and a higher percentage of partici-
pants who worsened specifically on EDE-Q subscales. However,
these percentages were not statistically significantly different from
the NT-AN group nor from the NTO-AN subset, nor were they clin-
ically significant or concerning. Moreover, the TD-AN subset
improved across all biological, BMI, and self-report measures.
Finally, the regression models (i.e., comparing the T-AN group to
the NT-AN group, the T-AN group to the NTO-AN subset, the
TD-AN subset to the NT-AN group, and the TD-AN subset to the
NTO-AN subset) were statistically significant across all comparisons
for EDE-Q-restraint subscale and indicated that group status was
also significant for PHQ-9 scores when comparing the T-AN
group to the NTO-AN subset. These findings suggest that the
T-AN group endorses higher restraint concerns and symptoms of
depression above and beyond their admission scores.
When analyses were repeated using 10 random subsamples
matched for sample size, only age (comparing the T-AN group to
the NT-AN group and the TD-AN subset to the NT-AN group)
was consistently statistically significant. Otherwise, results were
overwhelmingly either nonsignificant, or, if significant, in the direc-
tion opposite that expected by T-AN proponents (i.e., over 99% of
the results). The only conceivable pattern in our findings in support
of the T-AN concept (i.e., less than one percent of the results) was
that six results out of 40 involved higher mean levels of EDE-
Q-restraint concerns at discharge among the T-AN group in the
regression analyses.
Taken together, the information presented here indicates that the
groups labeled “terminal” do experience a severe illness, but that
these groups are not homogenous, do not appear to be meaningfully
different from those categorized as “not terminal,” and show overall
improvement from admission to discharge, similar to the “not terminal”
groups. Thus, the results presented in this study suggest that the use of a
“terminal” label for any client with AN meeting the criteria outlined by
Gaudiani et al. is premature and potentially unsupportable.
Limitations
While our study provides evidence against the existence of a “ter-
minal” course of AN, we acknowledge limitations of our findings.
Most obviously, we did not directly assess the fourth specifier in
Gaudiani et al.’s (2022, p. 1) definition of T-AN: “clear and consis-
tent determination by a patient who possesses decision-making
capacity that additional treatment would be futile… and they accept
that death will be the natural outcome” (italics added). Although we
examined the TD-AN subset who met a proxy index for this fourth
criterion (i.e., desire for death) and demonstrated that this subset is
similar to the larger T-AN group, we likely did not fully assess the
fourth criterion as it was intended. Thus, we can only speak fully
to a definition of terminality operationalized primarily by the first
three of four criteria proposed for T-AN. We did, however, approx-
imate the fourth criterion, especially its emphasis on death ideation
(see italicized phrase above). We emphasize that the item in question
is not an optimal index of the death-related criterion proposed by
Gaudiani et al., we urge readers to consider this important point in
interpreting our findings, and we encourage future work using a
more precise index of the relevant criterion as originally described
by Gaudiani et al. We would add that this criterion strikes us as
the most subjective of the four criteria and is the only one to rely
on patient rather than clinician judgment—a potentially problematic
basis on which to affix a terminal label.
Because there were no established effects between groups of inter-
est from which to draw, power analyses were only conducted post hoc
using observed effect sizes. Unsurprisingly, power varied greatly
based on observed effects, ranging from .05 to .99, which may indi-
cate a true lack of difference in a sample size below the thousands.
We acknowledge that sample sizes were relatively small for our “ter-
minal” groups, which limited statistical power. One view of our
efforts herein is that we simply showed that standard deviations
are typically larger for smaller cell sizes, unsurprising because the
formula for the standard deviation includes group size, or that under-
powered analyses typically do not return significant effects, and
we encourage readers to weigh this conclusion against our own:
Namely, that the totality of evidence we present here is at least
suggestive of the potential invalidity of the T-AN concept.
Specifically, regarding standard deviations, we add that while it is
of course true that group size is included in the formula for the stan-
dard deviation, it is also true in our view that in truly terminal ill-
nesses, variability should nonetheless be low specifically regarding
key illness-related parameters. Here, it was not. Efforts to replicate
our findings with larger samples are of course encouraged, though
we acknowledge that such projects are inherently challenging from
 TERMINAL ANOREXIA NERVOSA
a pragmatic point of view, given the need for large numbers of people
with a clinically severe form of a relatively rare illness.
Additionally, we note that Gaudiani et al. do not specifically state
that the T-AN diagnosis is accompanied by a worsening of symp-
toms; nevertheless, there is abundant language highly suggestive
to that effect (i.e., “hazarding psychological risk and deterioration”,
p. 12). Thus, as it is likely that true terminality is related to physical
deterioration, we included four relevant physiological parameters
(i.e., BMI, albumin levels, AST levels, and WBCs) in this study.
However, data on only three of the four biological parameters
were available at discharge, limiting our ability to assess change in
WBCs across treatment. We would also like to underscore our attri-
tion rates, as referenced above (see Footnote 1). In addition, we reit-
erate the point that conclusive arbitration of AN’s terminality may
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
prove empirically elusive, in that such questions invariably involve
values, ethics, and philosophy. It is a defensible if debatable point
of view that there are some questions—many of them philosophical
in nature—that are forever beyond the reach of empirical scrutiny,
and AN’s terminality or lack of it may be one such question
(a point that would apply to the terminality of any psychiatric con-
dition). Still, Guadiani and colleagues’ proposal of T-AN has an
empirical character, in that they are defining the construct using
quantifiable metrics (e.g., presence vs. absence of the AN diagnosis,
age, etc.). If Guadiani and colleagues are arguing that T-AN is a
valid clinical construct in nature, potentially one that could appear
in future editions of the DSM (e.g., as a specifier)—and we believe
they are—then our view is that empirical scrutiny is essential, and
that is what we strive to provide here. Finally, our study covered a
3-year period from 2020 to 2023, a time of the COVID-19 pandemic
and thus likely not necessarily representative of other timeframes.
Furthermore, admission-to-discharge timeframes were relatively
brief and may not have fully captured the timeline of treatment pro-
gression; nevertheless, we would expect to see a consistent and
homogenous decline in the T-AN group if it were truly terminal,
yet these data show very few such outcomes.
Conclusion
The current study is the first to our knowledge to empirically
examine the concept of terminality in AN based on the criteria pre-
sented for T-AN as proposed by Gaudiani et al. (2022). Findings
suggest that those meeting three of the four criteria of T-AN, as
well as those additionally meeting a proxy for the fourth criterion,
experience a severe illness marked by both psychological and phys-
iological symptoms; however, this group was, for the most part, not
significantly different from others with AN and showed similar
improvement across treatment, inconsistent with the “terminal” des-
ignation. Thus, future studies should continue to examine the con-
cept of terminality, explore the implications of terminal diagnoses,
and research further evidence of the existence of terminality within
mental health diagnoses. On this latter point, the stakes are high; the
empirical support should therefore be commensurately clear; data
presented here are relatively unsupportive.
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Received October 10, 2023
Revision received February 23, 2024
Accepted February 24, 2024 ▪