Skip to main content Accesibility Help

Patterns of diagnostic transition in eating disorders: a longitudinal population study in Sweden

  • Katherine Schaumberg (a1), Andreas Jangmo (a2), Laura M. Thornton (a1), Andreas Birgegård (a3), Catarina Almqvist (a2) (a4), Claes Norring (a3) (a5), Henrik Larsson (a2) and Cynthia M. Bulik (a1) (a2) (a6)...

Transition across eating disorder diagnoses is common, reflecting instability of specific eating disorder presentations. Previous studies have examined temporal stability of diagnoses in adult treatment-seeking samples but have not uniformly captured initial presentation for treatment. The current study examines transitions across eating disorder diagnostic categories in a large, treatment-seeking sample of individuals born in Sweden and compares these transitions across two birth cohorts and from initial diagnosis.


Data from Swedish eating disorders quality registers were extracted in 2013, including 9622 individuals who were seen at least twice from 1999 to 2013. Patterns of remission were examined in the entire sample and subsequently compared across initial diagnoses. An older (born prior to 1990) and younger birth cohort were also identified, and analyses compared these cohorts on patterns of diagnostic transition.


Although diagnostic instability was common, transition between threshold eating disorder diagnoses was infrequent. For all diagnoses, transition to remission was likely to occur following a diagnosis state that matched initial diagnosis, or through a subthreshold diagnostic state. Individuals in the younger cohort were more likely to transition to a state of remission than those in the older cohort.


Results indicate more temporal continuity in eating disorder presentations than suggested by previous research and highlight the importance of early detection and intervention in achieving remission.

Corresponding author
Author for correspondence: Cynthia M. Bulik, E-mail:
Hide All

These authors contributed equally to this work.

Hide All
Ackard, DM, Fulkerson, JA and Neumark-Sztainer, D (2011) Stability of eating disorder diagnostic classifications in adolescents: five-year longitudinal findings from a population-based study. Eating Disorders 19, 308322.
Agras, WS, Crow, S, Mitchell, JE, Halmi, KA and Bryson, S (2009) A 4-year prospective study of eating disorder NOS compared with full eating disorder syndromes. International Journal of Eating Disorders 42, 565570.
American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders, 4th Edn. Text Revision. Washington, DC: American Psychiatric Press.
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th Edn. Arlington, VA: American Psychiatric Press.
Birgegård, A, Björck, C and Clinton, D (2010) Quality assurance of specialised treatment of eating disorders using large-scale Internet-based collection systems: methods, results and lessons learned from designing the Stepwise database. European Eating Disorders Review 18, 251259.
Bulik, CM, Sullivan, PF, Fear, J and Pickering, A (1997) Predictors of the development of bulimia nervosa in women with anorexia nervosa. The Journal of Nervous and Mental Disease 185, 704707.
Castellini, G, Lo Sauro, C, Mannucci, E, Ravaldi, C, Rotella, CM, Faravelli, C and Ricca, V (2011) Diagnostic crossover and outcome predictors in eating disorders according to DSM-IV and DSM-V proposed criteria: a 6-year follow-up study. Psychosomatic Medicine 73, 270279.
D'Onofrio, BM, Class, QA, Rickert, ME, Larsson, H, Langstrom, N and Lichtenstein, P (2013) Preterm birth and mortality and morbidity: a population-based quasi-experimental study. JAMA Psychiatry 70, 12311240.
de Man Lapidoth, J and Birgegård, A (2010) A Validation of the Structured Eating Disorder Interview (SEDI) against the Eating Disorder Examination (EDE). Stockholm: Karolinska Institutet.
Eddy, KT, Dorer, DJ, Franko, DL, Tahilani, K, Thompson-Brenner, H, Herzog, DB (2007) Should bulimia nervosa be subtyped by history of anorexia nervosa? A longitudinal validation. International Journal of Eating Disorders 40, 567571.
Eddy, KT, Dorer, DJ, Franko, DL, Tahilani, K, Thompson-Brenner, H and Herzog, DB (2008) Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V. American Journal of Psychiatry 165, 245250.
Eddy, KT, Swanson, SA, Crosby, RD, Franko, DL, Engel, S and Herzog, DB (2010) How should DSM-V classify eating disorder not otherwise specified (EDNOS) presentations in women with lifetime anorexia or bulimia nervosa. Psychological Medicine 40, 17351744.
Ekbom, A (2011) The Swedish Multi-generation Register. Methods in Molecular Biology 675, 215220.
Ekeroth, K, Clinton, D, Norring, C and Birgegård, A (2013) Clinical characteristics and distinctiveness of DSM-5 eating disorder diagnoses: findings from a large naturalistic clinical database. Journal of Eating Disorders 1, 31.
Fairburn, C, Stice, E, Cooper, Z, Doll, H, Norman, P and O'Conner, M (2003) Understanding persistence in bulimia nervosa: a 5-year naturalistic study. Journal of Consulting and Clinical Psychology 71, 103109.
First, MB, Spitzer, R, Gibbon, M and Williams, JB (2002) Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version. Patent Edition (SCID-I/P), Biometrics Research, New York State Psychiatric Institute, New York.
Forbush, KT, Siew, CS and Vitevitch, MS (2016) Application of network analysis to identify interactive systems of eating disorder psychopathology. Psychological Medicine 46, 26672677.
Herpertz, S, Hagenah, U, Vocks, S, con Wietersheim, J, Cuntz, U and Zeeck, A (2011) The diagnosis and treatment of eating disorders. Deutsches Ärzteblatt International 108, 678685.
McElroy, SL, Guerdjikova, AI, Mori, N and Keck, PE Jr. (2015) Psychopharmacologic treatment of eating disorders: emerging findings. Current Psychiatry Reports 17, 35.
Milos, G, Spindler, A, Schnyder, U and Fairburn, CG (2005) Instability of eating disorder diagnoses: prospective study. The British Journal of Psychiatry 187, 573578.
Monteleone, P, Di Genio, M, Monteleone, AM, Di Filippo, C and Maj, M (2011) Investigation of factors associated to crossover from anorexia nervosa restricting type (ANR) and anorexia nervosa binge-purging type (ANBP) to bulimia nervosa and comparison of bulimia nervosa patients with or without previous ANR or ANBP. Comprehensive Psychiatry 52, 5662.
National Board of Health and Welfare (2010) Causes of Death 2008 Stockholm. Sweden: National Board of Health and Welfare.
Runfola, CD, Thornton, LM, Pisetsky, EM, Bulik, CM and Birgegard, A (2014) Self-image and suicide in a Swedish national eating disorders clinical register. Comprehensive Psychiatry 55, 439449.
Sandeberg, A-M, Birgegård, A, Mohlin, L, Nordlander Ström, C, Norring, C and Siverstrand, M-L. (2009) Regionalt Vårdprogram Ätstörningar. Stockholms Läns Landsting. Available at
Stice, E, Marti, CN and Rohde, P (2013) Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women. Journal of Abnormal Psychology 122, 445457.
Stice, E, Marti, CN, Shaw, H and Jaconis, M (2009) An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. Journal of Abnormal Psychology 118, 587597.
Swedish Association of Local Authorities and Regions (2007) National Healthcare Quality Registries in Sweden. Stockholm: KLF Grafisk Producation, Edita.
Tozzi, F, Thornton, L, Klump, K, Bulik, C, Fichter, M, Halmi, K, Kaplan, A, Strober, M, Woodside, D, Crow, S, Mitchell, J, Rotondo, A, Mauri, M, Cassano, C, Keel, P, Plotnicov, K, Pollice, C, Lilenfeld, L, Berrettini, W and Kaye, W (2005) Symptom fluctuation in eating disorders: correlates of diagnostic crossover. American Journal of Psychiatry 162, 732740.
Treasure, J and Russell, G (2011) The case for early intervention in anorexia nervosa: theoretical exploration of maintaining factors. British Journal of Psychiatry 199, 57.
Treasure, J, Stein, D and Maguire, S (2015) Has the time come for a staging model to map the course of eating disorders from high risk to severe enduring illness? An examination of the evidence. Early Intervention in Psychiatry 9, 173184.
Welch, E, Jangmo, A, Thornton, LM, Norring, C, von Hausswolff-Juhlin, Y, Herman, BK, Pawaskar, M, Larsson, H and Bulik, CM (2016) Treatment-seeking patients with binge-eating disorder in the Swedish national registers: clinical course and psychiatric comorbidity. BMC Psychiatry 16, 163.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed