Rethinking crossover and recovery in eating disorders through a dynamic and value-sensitive framework

Eating Disorders (EDs) raise significant challenges from a diagnostic and nosological perspective. Much of this is due to the extensive overlap among diagnostic criteria, with symptoms being shared by several conditions and subtypes. This nosological uncertainty is further exacerbated by two additional features of EDs, which will be the focus of this paper, namely diagnostic crossover and recovery. First, patients who acquire or lose one or more symptoms over time (symptom shifting) often transition to a new diagnostic category (crossover). Second, researchers working on EDs have recently underscored a problematic lack of inclusion of patients’ perspective on diagnostic and recovery processes, which results in an incomplete understanding of key aspects of EDs. Drawing on theoretical frameworks and concepts from Dynamical Systems Theory and epigenetics, we present a dynamic characterization of EDs that allows us to tackle the challenges of crossover and recovery. In our framework, different conditions represent robust endpoints in individuals’ developmental trajectories that are nonetheless flexible in certain circumstances. Thinking about EDs in diachronic terms also prompts us to significantly reframe our notion of recovery, not so much as the return to health but as the generation of future healthy trajectories, to be pursued in compliance with patients’ self-perception and aims. Indeed, the key role of patients’ values in determining their future trajectories testifies how psychiatric categories are not merely descriptive but constitutive, influencing both self-understanding and clinical practice.