A Study of Remission Criteria in Anorexia Nervosa: A Multidimensional Exploratory Observational Study of Recovery Among Patients in Remission According to the Bardone-Cone Criteria (ECRAM)

Anorexia nervosa is a severe eating disorder (ED) that may have a lasting impact on quality of life and psychosocial functioning. Its course, which is often prolonged, may be characterised by periods of improvement, relapses, or the persistence of clinical impairments.

The course of anorexia nervosa remains heterogeneous: some patients experience sustained remission, whereas others experience repeated relapses or a chronic course. This diversity of trajectories has been documented by long-term follow-up studies and by studies investigating relapse and the longitudinal validity of recovery criteria. This explains why the definition of remission represents a major issue for both clinical practice and research.

Methods for assessing recovery remain variable across studies, particularly with regard to the consideration of functional and subjective dimensions. Studies rely on different combinations of criteria, which limits their comparability, makes it difficult to interpret remission and relapse rates reported in the literature, and complicates the identification of a common approach to recovery.

In this context, the multidimensional operationalisation proposed by Bardone-Cone et al., initially validated in 2010 and subsequently evaluated longitudinally in 2019, represents an important step towards standardising the assessment of recovery. Work published in 2025 further supports its relevance by comparing several operational definitions of remission .

This study therefore aims to explore the characteristics of patients considered to be in remission according to the criteria proposed by Bardone-Cone et al. and to describe any discrepancies between this remission status and different clinical, functional, and subjective dimensions of recovery. It does not aim to propose a new definition of remission, but rather to contribute to a better understanding of the dimensions associated with recovery in anorexia nervosa.

The results will help to better characterise the profiles of patients in remission and generate hypotheses for future studies aiming to further investigate the assessment of recovery in anorexia nervosa.

1.1. Current state of knowledge

1.1.1. The disease

According to the DSM-5, anorexia nervosa is an eating disorder characterised by persistent restriction of energy intake leading to a significantly low body weight relative to age, sex, and physical health. It is accompanied by an intense fear of gaining weight or becoming fat, which persists despite significantly low body weight, as well as by a disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

The lifetime prevalence of anorexia nervosa is estimated at between 0.8 and 3.6% in women and around 0.1% in men, according to DSM-5 data. The disorder most commonly begins during adolescence or young adulthood. In the general population, the mean duration of anorexia nervosa is between 1.7 and 3 years, although the course may be shorter or chronic in a substantial proportion of patients.

Anorexia nervosa is associated with one of the highest mortality rates among psychiatric disorders, notably due to severe physical complications but also because of an increased risk of suicide. It is associated with substantial excess mortality compared with the general population of the same age, estimated to be approximately 5.2 times that observed in this population .

Furthermore, anorexia nervosa is frequently associated with psychiatric comorbidities. A nationally representative study showed that 87.3% of adults with anorexia nervosa met the criteria for at least one other psychiatric disorder, compared with 57.6% of individuals without an eating disorder.

Despite advances in the understanding and management of anorexia nervosa, its course remains heterogeneous. The meta-analysis by Steinhausen reported approximately 47% recovery, 33% improvement, and 20% chronic course at the end of follow-up.

In this context, the concept of remission plays a central role in the assessment of clinical trajectories. However, the absence of a consensual definition complicates the comparison of studies and contributes to the variability in relapse rates reported after treatment.

1.1.2. Standard and investigational treatments/strategies/procedures

The management of anorexia nervosa is based on a comprehensive and multidisciplinary approach involving psychiatric, nutritional, and psychotherapeutic care, taking into account the severity of the disorder, its duration, and associated psychiatric and non-psychiatric comorbidities.

Standard therapeutic strategies primarily aim to restore body weight and prevent physical complications, while simultaneously addressing the psychopathological dimensions of the disorder. Nutritional management plays a central role and aims to progressively normalise food intake and reduce restrictive and controlling behaviours. The initial objective of psychotherapeutic management is to promote engagement in care and the therapeutic alliance. In adults, randomised controlled trials have shown that several individual approaches may be effective, with none clearly emerging as superior, while treatment suitability and the quality of the therapeutic relationship remain key factors. Techniques used include cognitive behavioural therapy, interpersonal therapy, and psychodynamic approaches.

To date, no pharmacological treatment has demonstrated specific efficacy on the symptoms of anorexia nervosa. Pharmacological treatments are mainly used to manage psychiatric comorbidities, such as anxiety or depressive disorders.

Several studies have highlighted the impact of the choice of remission criteria on the assessment of clinical trajectories and treatment outcomes in anorexia nervosa. These findings emphasise the heterogeneous nature of the concept of remission and the major influence of the criteria used on the interpretation of clinical and research data.

In order to improve the standardisation of remission in eating disorders, Bardone-Cone et al. proposed a multidimensional operational definition of recovery in 2010. This definition combines three components: weight restoration, the absence of pathological eating behaviours, and normalisation of eating disorder psychopathology. Its concurrent and predictive validity was subsequently investigated longitudinally in 2019, and its relevance was reassessed in 2025 through a comparison of several operational definitions of remission.

This operationalisation currently represents one of the most structured and most frequently used definitions in research on recovery from eating disorders. It facilitates the harmonisation of criteria and the comparability of studies. However, it does not constitute a consensual or comprehensive definition of recovery.

Several limitations can indeed be identified. First, these criteria do not directly assess certain symptoms that may persist after weight and behavioural normalisation, such as anxiety or certain cognitive difficulties. Second, they do not explicitly incorporate the functional, social, or relational impact of the illness, nor psychiatric comorbidities. Third, they do not take into account the patient's subjective perception of recovery, although this plays an important role in contemporary conceptualisations of recovery.

Subjective experience has also been less extensively explored in studies of remission from eating disorders than clinical criteria defined by healthcare professionals. Nevertheless, contemporary models of recovery emphasise the value of incorporating the individual's subjective experience into the assessment of their progress.

It therefore appears essential to us to incorporate patients' perspectives into the consideration of remission, in order to better understand how they perceive their progress and recovery. Taking subjective experience into account may help to better mobilise patients' motivational factors, strengthen the therapeutic alliance, and promote adherence to the proposed treatments.

In this context, it appears relevant to examine the extent to which remission status defined according to the criteria proposed by Bardone-Cone et al., currently considered a reference definition, at least in a research context, is associated with the different dimensions of recovery, particularly clinical, functional, and subjective dimensions.