Clinical staging in eating disorders: qualitative insights from those with lived experience, carers, and clinicians

Background Clinical staging offers a framework for understanding and treating psychiatric disorders along a continuum and across dimensions, yet its application to eating disorders (EDs) remains limited. This study aimed to qualitatively explore clinical staging and stage modifiers in EDs across those with lived experience, carers, and clinicians. Methods Under a critical realist ontological stance, semi-structured interviews and focus groups were conducted with 21 participants (10 with lived ED experience, 2 carers, 9 clinicians). Data were analysed using Fryer’s critical realist approach to thematic analysis. Themes were developed as nuanced causal explanations of participants’ accounts of illness development, progression, treatment experiences, and recovery. Results Five superordinate themes were identified: (1) Clinical staging: seeking structure in a fluid illness (2) How eating disorders take hold, and hold on, (3) The wider forces shaping illness trajectories, (4) Healthcare experiences influence illness progression, and (5) Recovery: building life beyond the ED. Staging could largely be interpreted as an accurate framework for conceptualising EDs. However, EDs were consistently described as following a non-linear trajectory and concerns were raised on whether stages would be interpreted rigidly. Early intervention was considered crucial to prevent illness progression, but several barriers to early ED treatment were identified. Harmful treatment experiences were seen as shaping illness progression and stages. Conclusions The results suggest a preference for staging approaches that are flexible and person‑centred, and that can accommodate individual differences, non‑linear illness trajectories, and stage‑modifying factors. These novel insights demonstrate the value of stakeholder input in informing the development and refinement of clinical staging models for EDs.