Not niche: eating disorders as an example in the dangers of overspecialisation.

There are real-world consequences of the overspecialisation within eating disorder research, which result in a deleterious cycle ( Fig. 1 ). The less eating disorders are discussed in psychiatric training, journals and conferences, the less exposure professionals receive to this topic ( Fig. 1(a) ), which decreases the number of researchers and clinicians knowledgeable about eating disorders ( Fig. 1(b) ). Accordingly, psychiatric professionals are less likely to know of and collaborate with eating disorder researchers, apply for grants with eating disorder-focused projects or include eating disorder assessments in studies. New trainees, especially those historically under-represented in the eating disorder field, may not become familiar enough with eating disorder topics to pursue work in this area. Each of these issues can obstruct avenues for grant funding or high-impact, general-interest publications on eating disorders ( Fig. 1(c) ). Minimal exposure to information about eating disorders can also influence grant reviewers’ familiarity with the topic, potentially yielding uninformed and unenthusiastic reviews. Less research funding results in fewer well-resourced studies. For example, the authors of a letter to the American Journal of Psychiatry examined data on the quality of randomised controlled trials on eating disorders compared with panic disorder and agoraphobia, finding that studies on eating disorders were rated of lower quality. 5 They argued that lower-quality studies, rather than systematic bias and underfunding, were responsible for under-representation of eating disorder studies in high-impact journals. That correspondence was published 20 years ago and may not reflect current quality standards. However, if the quality of eating disorder research continues to be a concern, we raise the possibility that this reduced quality may not just be a cause, but also a consequence of the overspecialisation cycle described above. Lack of exposure to a topic can have an impact on the likelihood of funding for that topic, thereby affecting the quality of research on it and perpetuating the cycle. These issues have downstream effects on the resources and workforce available to identify and treat these serious disorders ( Fig. 1(d) ). These damages are already apparent. Most healthcare providers do not receive training in eating disorders and do not assess for or treat these disorders. Most eating disorders go undetected, untreated or ineffectively treated; less than 20% of individuals with an eating disorder ever receive treatment. The mechanisms promoting eating disorders remain poorly understood and eating disorder treatment effects have not improved in decades. Overspecialisation of eating disorders also limits the ability to identify transdiagnostic mechanisms that account for comorbidity between eating disorders and other disorders, possibly impeding progress on both sides. A literature review by Ahuvia et al found that body image interventions decrease depression to the same degree as treatments specifically targeting depression – reinforcing the value and need for other fields to collaborate with eating disorder researchers. Ultimately, the above cycle results in less high-quality research being conducted on serious illnesses that can be fatal.

It is unclear why eating disorders have been subject to more specialisation than other psychiatric disorders. One potential reason is that eating disorders have been inaccurately stereotyped as affecting only young, White, affluent, cisgender women. Although this misperception has been recently challenged by data demonstrating that eating disorders affect broader demographics than previously acknowledged, the harmful effects of this stereotype have likely perpetuated beliefs that eating disorders affect only a very specific segment of people. Additionally, whether or not it is reflective of the overall demographics of eating disorders, women are over-represented among eating disorder research samples (∼95% of participants in eating disorder studies) and professionals (∼84% of eating disorder academics are women, compared with ∼40–55% in broader academic mental health). It is documented that women are disadvantaged in high-impact publishing and grant funding (even within the female-dominated eating disorder field) 1 and disorders that disproportionally affect women (e.g. endometriosis, premenstrual dysphoric disorder) are underfunded relative to disease burden. Therefore, the potential for gender bias underlying the overspecialisation of eating disorder research warrants consideration. Finally, eating disorders carry a unique physical risk, often necessitating specific interventions for medical stabilisation, which may enhance clinical specialisation.

This Editorial is a call to action for funders, editors and researchers to take steps towards reducing misperceptions that silo eating disorders from other disciplines, with the end goal of promoting greater funding, high-impact research and access to treatment for these disorders. In Table 1 , we provide recommendations on how to extend the eating disorder field’s reach. Overspecialisation is not unique to eating disorders; therefore, these recommendations are relevant to other disorders frequently considered niche (e.g. personality disorders). Our aim is widespread recognition that, although eating disorders are many things – serious, puzzling, life-threatening – they are not niche.

The overspecialisation of eating disorders may imply that these disorders are uncommon, disconnected from other mental illnesses and of lesser interest than other psychiatric concerns. Not only are these assumptions false, but they can reinforce the artificial barriers between psychiatric subfields and stall the development of effective supports for patients. The point prevalence of eating disorders is ∼8% when using narrow classification standards and ∼19% when using broader definitions. 3 Even these may be low estimates given the use of potentially biased methods (e.g. retrospective chart review). Eating disorder prevalence is also increasing. Since the appearance of COVID-19, hospital admissions for eating disorders have doubled and adolescent emergency visits have more rapidly increased for eating disorders than for other psychiatric concerns. Further, although certain forms of eating disorder behaviour (e.g. self-induced vomiting) may be relatively uncommon in the general population, at least one analysis suggests that ∼50% of adolescents and adults engage in subclinical forms of disordered restrictive eating. Even subclinical disordered eating has been linked to myriad negative consequences (e.g. suicide, non-suicidal self-injury). Eating disorders are highly comorbid with other psychiatric disorders, including those considered more commonplace (e.g. depression, anxiety); 95% of individuals with an eating disorder have a co-occurring affective disorder and at least 20–35% of those with an affective disorder have an eating disorder. This elevated comorbidity suggests overlapping mechanisms between eating disorders and other psychiatric concerns. Eating disorder symptoms complicate treatment of other psychiatric disorders, highlighting the necessity of attending to eating disorder symptoms in general psychiatry. Despite eating disorder articles being under-published in general psychiatry journals, the most downloaded publication of 2021 from the high-impact outlet JAMA Psychiatry focused on the neurobiology of anorexia nervosa. 4 This metric is especially striking given that <2% of JAMA Psychiatry articles in 2021 focused on eating disorder samples (versus ∼16% on schizophrenia). This demonstrates a clear, widespread interest in eating disorder research, despite under-representation. Additionally, we argue that eating disorders are of urgent importance to psychiatry regardless of whether they garner general interest. Eating disorders are severe, debilitating, often persistent, and costly (∼$400 billion/year in the USA). Anorexia nervosa is second only to opioid use disorder in lethality and other eating disorders share high premature mortality. Providers are often faced with life-or-death decisions in eating disorder care. These facts alone warrant increased attention on eating disorder research.