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The field of eating disorders has notable problems of definition. For this year’s Editorial we were stimulated to focus on this because it is both the year of pre-release of the 11th Edition of the International Classification of Diseases (ICD-11) [1] and PH was invited to present a paper on recovery in eating disorders. In doing so it became clear that there is little consensus for definitions for recovery [2] or more broadly other important clinical phases of anorexia nervosa. In particular, definitions of severe and/ or enduring illness are elusive and the concept of ‘severe and enduring’ is frequently misunderstood in terms of its conceptualisation [3, 4]. Such lack of definitional clarity is a problem for researchers, but even more so for clinicians who become confused, and most importantly for those living with the eating disorder. Despite lack of definitional clarity, people with unremitting anorexia nervosa have very poor outcomes [5, 6] and there is little evidence based treatment for their care [7, 8]. Only in the twenty-first century was an attempt made to incorporate recommendations for this group into clinical practice guidelines [8]. However, these guidelines referred to implicit clinical descriptors of longstanding illness with high morbidity, poor function and high health care use. In contrast diagnostic schemes such as the ICD-11 and Diagnostic and Statistical Manual of Mental Disorders Fifth edition (DSM-5) [9]) have explicit threshold criteria for persons to achieve a categorical diagnosis. The guidelines [8] did not apply or suggest specific criteria for severe and enduring anorexia nervosa as there are none agreed – or discuss other severe and enduring eating disorders. Clear definitions are very important. They are the reason the DSM-III in 1980 was universally popular to the point that copies had to be chained to desks to prevent their theft by students in the hospitals where we (PH and ST) then worked. The understanding of aetiology, prognosis and the relationships between disorders rests on precise diagnosis, and valid and reliable diagnostic systems are necessary for meaningful communication between clinicians and researchers [10]. Let’s examine ‘severe and enduring’ anorexia nervosa as it is conceptualised and then as it may be defined. We purport there are three components of severe and enduring anorexia nervosa: persistent unremitting symptoms, of long duration, and treatment resistance. First, the DSM-5 has definitions of severe for anorexia nervosa based on levels of body mass index (BMI; kg/m) which are cross-sectional [9]. Dakanalis et al. found these definitions of severity predict or converge with other aspects of anorexia nervosa illness severity and functional impact [11]. However, in the case of unrelenting illness these should be tempered as a person with a decade or more years of a BMI above the DSM-5 severe range will have considerable morbidity from chronic starvation and longstanding illness – the latter term applied in the Touyz et al. randomised controlled trial of treatments for this group [7]. Second, considering duration, a systematic review reported that most who have written about this state in anorexia nervosa are referring to more than a few years of experiencing diagnostic level eating disorder symptoms with several previously failed treatment attempts [4]. The number of years of illness in the published literature ranges from 3 to 10, with a mode of 7 in this review [4]. In sum, the agreed lower limit of years appears to be three. The third key feature of treatment resistance is the most problematic to define. There are a diversity of approaches where individuals and/or their families have not responded to or do not wish to engage in first line therapies and also major differences across and often even within regions in how, when and what treatments patients are able to access. As a trainee psychiatrist I (PH) recall a common question in our examinations was “The specialist approach to assessment of a person with treatment resistant disorder X”. The answer always began with first, review the * Correspondence: p.hay@westernsydney.edu.au Translational Health Research Institute, School of Medicine, Western Sydney University, Sydney, Australia Full list of author information is available at the end of the article

Classification challenges in the field of eating disorders: can severe and enduring anorexia nervosa be better defined?