Not Niche: Eating Disorders and the Dangers of Over-specialization

Abstract

In this Commentary, my co-authors and I address the harmful, real-world effects of the over-specialization of eating disorders research within psychiatry, an issue that has broad and far-reaching impact upon mental health research and clinical care. Eating disorders impact up to ~20% of the population, cost the U.S., ~$400 billion/year, and carry the second highest mortality rate of any psychiatric illness (only slightly lower than opioid use disorder). Yet, these disorders are often considered “niche” specialty disorders. As such, they are consistent under-represented in broad-interest psychiatry journals and receive far less research funding than disorders with comparable prevalence rates (~$0.73 USD/affected individual for eating disorders research versus ~$86.97 USD/affected individual with schizophrenia). Highlighting this pattern, our literature search suggests that The American Journal of Psychiatry published > 4 times as many papers on psychotic disorders compared to eating disorders in 2021. However, this trend is not unique to this journal; eating disorder research is under-represented or under-valued across impact metrics within psychiatry. In this commentary, we: 1) address false assumptions about eating disorders that perpetuate the over-specialization of this field; 2) highlight how false assumptions about eating disorders obstruct critical progress in research and treatment; and, importantly, 3) provide concrete recommendations for extending the reach of the eating disorders research.

Realizing the untapped promise of single‐session interventions for eating disorders

“…Recent innovations in intervention science have spurred the development, evaluation, and dissemination of interventions that may help meet this need, including work evaluating relatively brief, digital and self‐guided, and lay‐provider delivered programs to treat and prevent a variety of mental health problems (O'Mara et al, 2023). However, only a small portion of these interventions explicitly target ED symptoms or risk factors, which reflects a history of siloing of ED‐focused treatment research from intervention research on depression, anxiety, and other common mental health problems (Haynos et al, Forthcoming). In addition to hampering integration of knowledge across ED‐ and non‐ED‐focused intervention research, this siloing may worsen rifts between ED research and practice, on the one hand, and patient needs and demands, on the other.…”

“…To optimize the relevance of SSI research to treating and preventing EDs, future trials must include validated assessments of diverse ED symptoms—even in trials of SSIs not explicitly targeting EDs. Although EDs have long been misrepresented within psychology and psychiatry training as “niche” disorders, they are highly comorbid with many common mental health concerns (Haynos et al, Forthcoming). As researchers continue to evaluate existing SSIs for common mental health problems, including depression and anxiety, we strongly recommend assessing their potential secondary impacts on ED‐relevant outcomes, including body image and eating concerns.…”

“…Despite the severity and societal cost of EDs, funding for ED research is low compared to other psychiatric disorders (Murray et al, 2017). Although a broader recognition that EDs are “not niche” disorders will be needed to address the root causes of inadequate investment in ED treatment (Haynos et al, Forthcoming), a more immediate path to expanding funding opportunities might involve capitalizing on the transdiagnostic utility of SSIs (e.g., for EDs and depression, per Schleider et al, 2022; Smith et al, Forthcoming). Transdiagnostic interventions have been considered a “best buy” due to their broad clinical scope and relative cost‐effectiveness (Kazdin et al, 2017); likewise, SSIs' potential for scalability is well‐suited to addressing large‐scale public health needs.…”

Project Body Neutrality: Piloting a digital single‐session intervention for adolescent body image and depression

“…Results of our pilot also carry broader implications for ED research and practice. In the broader psychology literature, EDs are often characterized as “niche” disorders that are rare and disconnected from other mental health disorders (Haynos et al, 2022). On the contrary, EDs are common and highly comorbid with other disorders, suggesting that interventions targeting shared risk factors may represent cost‐effective “best‐buys,” with broad public health applications (Kazdin et al, 2017).…”

Treatment of avoidant‐restrictive food intake disorder in an older adult: A proof‐of‐concept case study

“…Additionally, discussion with G and his medical providers revealed a lack of knowledge on ARFID, consistent with a lack of training for eating disorders (Linville et al, 2010). Clinicians and medical providers should familiarize themselves with ARFID symptom presentations, risk factors, and eating disorders generally (Haynos et al, 2022; Reid et al, 2010). Lastly, clinicians may improve treatment efficacy with ARFID clients by validating previous invalidations clients may have experienced (e.g., symptoms labeled as “picky‐eating”).…”