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  • How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

  • Search for relevant literature
  • Evaluate sources
  • Identify themes, debates, and gaps
  • Outline the structure
  • Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

  • Quick Run-through
  • Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

  • Demonstrate your familiarity with the topic and its scholarly context
  • Develop a theoretical framework and methodology for your research
  • Position your work in relation to other researchers and theorists
  • Show how your research addresses a gap or contributes to a debate
  • Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

Literature review guide

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

  • Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
  • Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
  • Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
  • Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

  • Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
  • Body image, self-perception, self-esteem, mental health
  • Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

  • Your university’s library catalogue
  • Google Scholar
  • Project Muse (humanities and social sciences)
  • Medline (life sciences and biomedicine)
  • EconLit (economics)
  • Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

  • What question or problem is the author addressing?
  • What are the key concepts and how are they defined?
  • What are the key theories, models, and methods?
  • Does the research use established frameworks or take an innovative approach?
  • What are the results and conclusions of the study?
  • How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
  • What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

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To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

  • Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
  • Themes: what questions or concepts recur across the literature?
  • Debates, conflicts and contradictions: where do sources disagree?
  • Pivotal publications: are there any influential theories or studies that changed the direction of the field?
  • Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

  • Most research has focused on young women.
  • There is an increasing interest in the visual aspects of social media.
  • But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).


The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.


If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

  • Look at what results have emerged in qualitative versus quantitative research
  • Discuss how the topic has been approached by empirical versus theoretical scholarship
  • Divide the literature into sociological, historical, and cultural sources


A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

  • Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
  • Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
  • Critically evaluate: mention the strengths and weaknesses of your sources
  • Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

  • Sampling methods
  • Simple random sampling
  • Stratified sampling
  • Cluster sampling
  • Likert scales
  • Reproducibility


  • Null hypothesis
  • Statistical power
  • Probability distribution
  • Effect size
  • Poisson distribution

Research bias

  • Optimism bias
  • Cognitive bias
  • Implicit bias
  • Hawthorne effect
  • Anchoring bias
  • Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

  • To familiarize yourself with the current state of knowledge on your topic
  • To ensure that you’re not just repeating what others have already done
  • To identify gaps in knowledge and unresolved problems that your research can address
  • To develop your theoretical framework and methodology
  • To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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  • Strategy: Literature Reviews

What is a literature review?

Typically, a literature review is a written discussion that examines publications about  a particular subject area or topic. 

research strategy literature review

A Literature Review provides an overview of selected sources on a topic.

Depending on disciplines, publications, or authors a literature review may be:  

a summary of sources an organized presentation of sources a synthesis or interpretation of sources an evaluative analysis of sources

A Literature Review may be part of a process or a product . 

It may be: 

a part of your research process a part of your final research publication an independent publication

Why do a literature review?

The Literature Review will place your research in context . 

It will help you and your readers: 

Locate   patterns, relationships, connections, agreements, disagreements, & gaps in understanding Identify methodological and theoretical foundations Identify landmark and exemplary works Situate your voice in a broader conversation with other writers, thinkers, and scholars

The Literature Review will aid your research process. 

It will help you to: 

establish your knowledge understand what has been said define your questions establish a relevant methodology refine your voice situate your voice in the conversation

What does a literature review look like?

The Literature Review structure and organization . 

an introduction or overview a body or organizational sub-divisions a conclusion or an explanation of significance

The body of a literature review may be organized: 

chronologically: organized by date of publication  methodologically: organized by type of research method used  thematically: organized by concept, trend, or theme  ideologically: organized by belief, ideology, or school of thought

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Writing a Literature Review

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A literature review is a document or section of a document that collects key sources on a topic and discusses those sources in conversation with each other (also called synthesis ). The lit review is an important genre in many disciplines, not just literature (i.e., the study of works of literature such as novels and plays). When we say “literature review” or refer to “the literature,” we are talking about the research ( scholarship ) in a given field. You will often see the terms “the research,” “the scholarship,” and “the literature” used mostly interchangeably.

Where, when, and why would I write a lit review?

There are a number of different situations where you might write a literature review, each with slightly different expectations; different disciplines, too, have field-specific expectations for what a literature review is and does. For instance, in the humanities, authors might include more overt argumentation and interpretation of source material in their literature reviews, whereas in the sciences, authors are more likely to report study designs and results in their literature reviews; these differences reflect these disciplines’ purposes and conventions in scholarship. You should always look at examples from your own discipline and talk to professors or mentors in your field to be sure you understand your discipline’s conventions, for literature reviews as well as for any other genre.

A literature review can be a part of a research paper or scholarly article, usually falling after the introduction and before the research methods sections. In these cases, the lit review just needs to cover scholarship that is important to the issue you are writing about; sometimes it will also cover key sources that informed your research methodology.

Lit reviews can also be standalone pieces, either as assignments in a class or as publications. In a class, a lit review may be assigned to help students familiarize themselves with a topic and with scholarship in their field, get an idea of the other researchers working on the topic they’re interested in, find gaps in existing research in order to propose new projects, and/or develop a theoretical framework and methodology for later research. As a publication, a lit review usually is meant to help make other scholars’ lives easier by collecting and summarizing, synthesizing, and analyzing existing research on a topic. This can be especially helpful for students or scholars getting into a new research area, or for directing an entire community of scholars toward questions that have not yet been answered.

What are the parts of a lit review?

Most lit reviews use a basic introduction-body-conclusion structure; if your lit review is part of a larger paper, the introduction and conclusion pieces may be just a few sentences while you focus most of your attention on the body. If your lit review is a standalone piece, the introduction and conclusion take up more space and give you a place to discuss your goals, research methods, and conclusions separately from where you discuss the literature itself.


  • An introductory paragraph that explains what your working topic and thesis is
  • A forecast of key topics or texts that will appear in the review
  • Potentially, a description of how you found sources and how you analyzed them for inclusion and discussion in the review (more often found in published, standalone literature reviews than in lit review sections in an article or research paper)
  • Summarize and synthesize: Give an overview of the main points of each source and combine them into a coherent whole
  • Analyze and interpret: Don’t just paraphrase other researchers – add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
  • Critically Evaluate: Mention the strengths and weaknesses of your sources
  • Write in well-structured paragraphs: Use transition words and topic sentence to draw connections, comparisons, and contrasts.


  • Summarize the key findings you have taken from the literature and emphasize their significance
  • Connect it back to your primary research question

How should I organize my lit review?

Lit reviews can take many different organizational patterns depending on what you are trying to accomplish with the review. Here are some examples:

  • Chronological : The simplest approach is to trace the development of the topic over time, which helps familiarize the audience with the topic (for instance if you are introducing something that is not commonly known in your field). If you choose this strategy, be careful to avoid simply listing and summarizing sources in order. Try to analyze the patterns, turning points, and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred (as mentioned previously, this may not be appropriate in your discipline — check with a teacher or mentor if you’re unsure).
  • Thematic : If you have found some recurring central themes that you will continue working with throughout your piece, you can organize your literature review into subsections that address different aspects of the topic. For example, if you are reviewing literature about women and religion, key themes can include the role of women in churches and the religious attitude towards women.
  • Qualitative versus quantitative research
  • Empirical versus theoretical scholarship
  • Divide the research by sociological, historical, or cultural sources
  • Theoretical : In many humanities articles, the literature review is the foundation for the theoretical framework. You can use it to discuss various theories, models, and definitions of key concepts. You can argue for the relevance of a specific theoretical approach or combine various theorical concepts to create a framework for your research.

What are some strategies or tips I can use while writing my lit review?

Any lit review is only as good as the research it discusses; make sure your sources are well-chosen and your research is thorough. Don’t be afraid to do more research if you discover a new thread as you’re writing. More info on the research process is available in our "Conducting Research" resources .

As you’re doing your research, create an annotated bibliography ( see our page on the this type of document ). Much of the information used in an annotated bibliography can be used also in a literature review, so you’ll be not only partially drafting your lit review as you research, but also developing your sense of the larger conversation going on among scholars, professionals, and any other stakeholders in your topic.

Usually you will need to synthesize research rather than just summarizing it. This means drawing connections between sources to create a picture of the scholarly conversation on a topic over time. Many student writers struggle to synthesize because they feel they don’t have anything to add to the scholars they are citing; here are some strategies to help you:

  • It often helps to remember that the point of these kinds of syntheses is to show your readers how you understand your research, to help them read the rest of your paper.
  • Writing teachers often say synthesis is like hosting a dinner party: imagine all your sources are together in a room, discussing your topic. What are they saying to each other?
  • Look at the in-text citations in each paragraph. Are you citing just one source for each paragraph? This usually indicates summary only. When you have multiple sources cited in a paragraph, you are more likely to be synthesizing them (not always, but often
  • Read more about synthesis here.

The most interesting literature reviews are often written as arguments (again, as mentioned at the beginning of the page, this is discipline-specific and doesn’t work for all situations). Often, the literature review is where you can establish your research as filling a particular gap or as relevant in a particular way. You have some chance to do this in your introduction in an article, but the literature review section gives a more extended opportunity to establish the conversation in the way you would like your readers to see it. You can choose the intellectual lineage you would like to be part of and whose definitions matter most to your thinking (mostly humanities-specific, but this goes for sciences as well). In addressing these points, you argue for your place in the conversation, which tends to make the lit review more compelling than a simple reporting of other sources.

Charles Sturt University

Literature Review: Developing a search strategy

  • Traditional or narrative literature reviews
  • Scoping Reviews
  • Systematic literature reviews
  • Annotated bibliography
  • Keeping up to date with literature
  • Finding a thesis
  • Evaluating sources and critical appraisal of literature
  • Managing and analysing your literature
  • Further reading and resources

From research question to search strategy

Keeping a record of your search activity

Good search practice could involve keeping a search diary or document detailing your search activities (Phelps et. al. 2007, pp. 128-149), so that you can keep track of effective search terms, or to help others to reproduce your steps and get the same results. 

This record could be a document, table or spreadsheet with:

  • The names of the sources you search and which provider you accessed them through - eg Medline (Ovid), Web of Science (Thomson Reuters). You should also include any other literature sources you used.
  • how you searched (keyword and/or subject headings)
  • which search terms you used (which words and phrases)
  • any search techniques you employed (truncation, adjacency, etc)
  • how you combined your search terms (AND/OR). Check out the Database Help guide for more tips on Boolean Searching.
  • The number of search results from each source and each strategy used. This can be the evidence you need to prove a gap in the literature, and confirms the importance of your research question.

A search planner may help you to organise you thoughts prior to conducting your search. If you have any problems with organising your thoughts prior, during and after searching please contact your Library  Faculty Team   for individual help.

  • Literature search - a librarian's handout to introduce tools, terms and techniques Created by Elsevier librarian, Katy Kavanagh Web, this document outlines tools, terms and techniques to think about when conducting a literature search.
  • Search planner

Literature search cycle

research strategy literature review

Diagram text description

This diagram illustrates the literature search cycle. It shows a circle in quarters. Top left quarter is identify main concepts with rectangle describing how to do this by identifying:controlled vocabulary terms, synonyms, keywords and spelling. Top right quarter select library resources to search and rectangle describing resources to search library catalogue relevant journal articles and other resource. Bottom right corner of circle search resources and in rectangle consider using boolean searching proximity searching and truncated searching techniques. Bottom left quarter of circle review and refine results. In rectangle evaluate results, rethink keywords and create alerts.

Have a search framework

Search frameworks are mnemonics which can help you focus your research question. They are also useful in helping you to identify the concepts and terms you will use in your literature search.

PICO is a search framework commonly used in the health sciences to focus clinical questions.  As an example, you work in an aged care facility and are interested in whether cranberry juice might help reduce the common occurrence of urinary tract infections.  The PICO framework would look like this:

Now that the issue has been broken up to its elements, it is easier to turn it into an answerable research question: “Does cranberry juice help reduce urinary tract infections in people living in aged care facilities?”

Other frameworks may be helpful, depending on your question and your field of interest. PICO can be adapted to PICOT (which adds T ime) or PICOS (which adds S tudy design), or PICOC (adding C ontext).

For qualitative questions you could use

  • SPIDER : S ample,  P henomenon of  I nterest,  D esign,  E valuation,  R esearch type  

For questions about causes or risk,

  • PEO : P opulation,  E xposure,  O utcomes

For evaluations of interventions or policies, 

  • SPICE: S etting,  P opulation or  P erspective,  I ntervention,  C omparison,  E valuation or
  • ECLIPSE: E xpectation,  C lient group,  L ocation,  I mpact,  P rofessionals,  SE rvice 

See the University of Notre Dame Australia’s examples of some of these frameworks. 

You can also try some PICO examples in the National Library of Medicine's PubMed training site: Using PICO to frame clinical questions.

Contact Your Faculty Team Librarian

Faculty librarians are here to provide assistance to students, researchers and academic staff by providing expert searching advice, research and curriculum support.

  • Faculty of Arts & Education team
  • Faculty of Business, Justice & Behavioural Science team
  • Faculty of Science team

Further reading

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  • Last Updated: Apr 10, 2024 5:05 PM
  • URL: https://libguides.csu.edu.au/review

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Conducting Literature Reviews

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Research Tips

  • Video: How to Narrow Your Topic This video from the Credo Information Literacy tutorials offers strategies for narrowing your topic.
  • Video: Thesis Statements Tips and strategies for constructing thesis statements.
  • Video: Choosing a Database Not sure where to begin? Watch this video to learn more about choosing a database for your research.
  • Video: Refining Search Results Tips and tricks for getting more relevant search results.

Conducting Research for a Literature Review

  • What is a Literature Review?
  • Steps in the Literature Review Process
  • Research Strategies

  • A “lit review” is a work (or section of a work) that presents the historical context AND current situation about a certain topic using writings by experts in the field.
  • The literature review adds to the ongoing scholarly conversation around a topic, by identifying past research and showing how the current research contributes to the body of knowledge.  Authors provide context for a thesis by  reviewing scholarly articles, books, dissertations, conference proceedings and other resources which are relevant to a particular issue.

Purpose of a Literature Review

  • Identifies gaps in current knowledge
  • Helps you to avoid reinventing the wheel by discovering the research already conducted on a topic
  • Sets the background on what has been explored on a topic so far Increases your breadth of knowledge in your area of research
  • Helps you identify seminal works in your area
  • Allows you to provide the intellectual context for your work and position your research with other, related research
  • Provides you with opposing viewpoints
  • Helps you to discover research methods which may be applicable to your work

Greenfield, T. (2002). Research methods for postgraduates. 2nd ed. London: Arnold.

1) Planning: identify the focus, type, scope and discipline of the review you intend to write. 2) Reading and Research: collect and read current research on your topic. Select only those sources that are most relevant to your project. 3) Analyzing: summarize, synthesize, critique, and compare your sources in order to assess the field of research as a whole. 4) Drafting: develop a thesis or claim to make about the existing research and decide how to organize your material. 5) Revising: revise and finalize the structural, stylistic, and grammatical issues of your paper.

This process is not always a linear process; depending on the size and scope of your literature review, you may find yourself returning to some of these steps repeatedly as you continue to focus your project.

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  • Literature Reviews: Strategies for Writing
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Literature Reviews

What is a Literature Review? The literature review is a critical look at the existing research that is significant to the work that you are carrying out. This overview identifies prominent research trends in addition to assessing the overall strengths and weaknesses of the existing research.

Purpose of the Literature Review

  • To provide background information about a research topic.
  • To establish the importance of a topic.
  • To demonstrate familiarity with a topic/problem.
  • To “carve out a space” for further work and allow you to position yourself in a scholarly conversation.

Characteristics of an effective literature review In addition to fulfilling the purposes outlined above, an effective literature review provides a critical overview of existing research by

  • Outlining important research trends.
  • Assessing strengths and weaknesses (of individual studies as well the existing research as a whole).
  • Identifying potential gaps in knowledge.
  • Establishing a need for current and/or future research projects.

Steps of the Literature Review Process

1) Planning: identify the focus, type, scope and discipline of the review you intend to write. 2) Reading and Research: collect and read current research on your topic. Select only those sources that are most relevant to your project. 3) Analyzing: summarize, synthesize, critique, and compare your sources in order to assess the field of research as a whole. 4) Drafting: develop a thesis or claim to make about the existing research and decide how to organize your material. 5) Revising: revise and finalize the structural, stylistic, and grammatical issues of your paper.

This process is not always a linear process; depending on the size and scope of your literature review, you may find yourself returning to some of these steps repeatedly as you continue to focus your project.

These steps adapted from the full workshop offered by the Graduate Writing Center at Penn State. 

Literature Review Format


  • Provide an overview of the topic, theme, or issue.
  • Identify your specific area of focus.
  • Describe your methodology and rationale. How did you decide which sources to include and which to exclude? Why? How is your review organized?
  • Briefly discuss the overall trends in the published scholarship in this area.
  •  Establish your reason for writing the review.
  •  Find the best organizational method for your review.
  •  Summarize sources by providing the most relevant information.
  •  Respectfully and objectively critique and evaluate the studies.
  •  Use direct quotations sparingly and only if appropriate.


  •  Summarize the major findings of the sources that you reviewed, remembering to keep the focus on your topic.
  •  Evaluate the current state of scholarship in this area (ex. flaws or gaps in the research, inconsistencies in findings) 
  •  Identify any areas for further research.
  •  Conclude by making a connection between your topic and some larger area of study such as the discipline. 
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Literature Reviews & Search Strategies

  • Defining the Literature Review
  • Types of Literature Reviews
  • Choosing Databases

Overview of Search Strategies

Search strategies, subject searching, example: iteratively developing + using keywords, demonstration: developing keywords from a question, demonstration: an advanced search.

  • Organizing Your Literature
  • Books: Research Design & Scholarly Writing
  • Recommended Tutorials

There are many ways to find literature for your review, and we recommend that you use a combination of strategies - keeping in mind that you're going to be searching multiple times in a variety of ways, using different databases and resources. Searching the literature is not a straightforward, linear process - it's iterative (translation: you'll search multiple times, modifying your strategies as you go, and sometimes it'll be frustrating). 

  • Known Item Searching
  • Citation Jumping

Some form of a keyword search is the way most of us get at scholarly articles in database - it's a great approach! Make sure you're familiar with these librarian strategies to get the most out of your searches.

Figuring out the best keywords for your research topic/question is a process - you'll start with one or a few words and then shift, adapt, and expand them as you start finding source that describe the topic using other words. Your search terms are the bridge between known topics and the unknowns of your research question - so sometimes one specific word will be enough, sometimes you'll need several different words to describe a concept AND you'll need to connect that concept to a second (and/or third) concept.

The number and specificity of your search terms depend on your topic and the scope of your literature review.

Connect Keywords Using Boolean

Make the database work more.

...uses the asterisk (*) to end a word at its core, allowing you to retrieve many more documents containing variations of the search term.  Example: educat* will find educate, educates, education, educators, educating and more.

Phrase Searching

...is when you put quotations marks around two or more words, so that the database looks for those words in that exact order. Examples: "higher education," "public health" and "pharmaceutical industry."

Controlled Vocabulary

... is when you use the terms the database uses to describe what each article is about as search terms. Searching using controlled vocabularies is a great way to get at everything on a topic in a database.  

Databases and search engines are probably going to bring back a lot of results - more than a human can realistically go through. Instead of trying to manually read and sort them all, use the filters in each database to remove the stuff you wouldn't use anyway (ie it's outside the scope of your project).

To make sure you're consistent between searches and databases, write down the filters you're using.

A Few Filters to Try

Once you know you have a good article , there are a lot of useful parts to it - far beyond the content.

Not sure where to start? Try course readings and other required materials.

Useful Parts of a Good Article

Ways to use citations.

  • Interactive Tutorial: Searching Cited and Citing Practice starting your search at an article and using the references to gather additional sources.

Older sources eat into the found article as references, and the found article is cited by more recent publications.

Your search results don't have to be frozen in the moment you search! There are a few things you can set up to keep your search going automatically.

Searching using subject headings is a comprehensive search strategy that requires some planning and topic knowledge. Work through this PubMed tutorial for an introduction to this important approach to searching.

tutorial on PubMed Subject Search: How it Works

Through these videos and the accompanying PDF, you'll see an example of starting with a potential research question and developing search terms through brainstorming and keyword searching.

  • Slidedeck: Keywords and Advanced Search PowerPoint slides to accompany the two demonstration videos on developing keywords from a question, and doing an advanced search.
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  • Subject guides
  • Researching for your literature review
  • Develop a search strategy

Researching for your literature review: Develop a search strategy

  • Literature reviews
  • Literature sources
  • Before you start
  • Keyword search activity
  • Subject search activity
  • Combined keyword and subject searching
  • Online tutorials
  • Apply search limits
  • Run a search in different databases
  • Supplementary searching
  • Save your searches
  • Manage results

Identify key terms and concepts

Start developing a search strategy by identifying the key words and concepts within your research question. The aim is to identify the words likely to have been used in the published literature on this topic.

For example: What are the key infection control strategies for preventing the transmission of Meticillin-resistant Staphylococcus aureus (MRSA) in aged care homes .

Treat each component as a separate concept so that your topic is organised into separate blocks (concepts).

For each concept block, list the key words derived from your research question, as well as any other relevant terms or synonyms that you have found in your preliminary searches. Also consider singular and plural forms of words, variant spellings, acronyms and relevant index terms (subject headings).  

As part of the process of developing a search strategy, it is recommended that you keep a master list of search terms for each key concept. This will make it easier when it comes to translating your search strategy across multiple database platforms. 

Concept map template for documenting search terms

Combine search terms and concepts

Boolean operators are used to combine the different concepts in your topic to form a search strategy. The main operators used to connect your terms are AND and OR . See an explanation below:

  • Link keywords related to a single concept with OR
  • Linking with OR broadens a search (increases the number of results) by searching for any of the alternative keywords

Example: nursing home OR aged care home

  • Link different concepts with AND
  • Linking with AND narrows a search (reduces the number of results) by retrieving only those records that include all of your specified keywords

Example: nursing home AND infection control

  • using NOT narrows a search by excluding results that contain certain search terms
  • Most searches do not require the use of the NOT operator

Example: aged care homes NOT residential homes will retrieve all the results that include the words aged care homes but don't include the words residential homes . So if an article discussed both concepts this article would not be retrieved as it would be excluded on the basis of the words residential homes .

See the website for venn diagrams demonstrating the function of AND/OR/NOT:

Combine the search terms using Boolean

Advanced search operators - truncation and wildcards

By using a truncation symbol you can capture all of the various endings possible for a particular word. This may increase the number of results and reduce the likelihood of missing something relevant. Some tips about truncation:

  • The truncation symbol is generally an asterisk symbol * and is added at the end of a word.
  • It may be added to the root of a word that is a word in itself. Example: prevent * will retrieve prevent, prevent ing , prevent ion prevent ative etc. It may also be added to the root of a word that is not a word in itself. Example: strateg * will retrieve strateg y , strateg ies , strateg ic , strateg ize etc.
  • If you don't want to retrieve all possible variations, an easy alternative is to utilise the OR operator instead e.g. strategy OR strategies. Always use OR instead of truncation where the root word is too small e.g. ill OR illness instead of ill*

There are also wildcard symbols that function like truncation but are often used in the middle of a word to replace zero, one or more characters.

  • Unlike the truncator which is usually an asterisk, wildcards vary across database platforms
  • Common wildcards symbols are the question mark ? and hash #.
  • Example:  wom # n finds woman or women, p ? ediatric finds pediatric or paediatric.  

See the Database search tips for details of these operators, or check the Help link in any database.

Phrase searching

For words that you want to keep as a phrase, place two or more words in "inverted commas" or "quote marks". This will ensure word order is maintained and that you only retrieve results that have those words appearing together.

Example: “nursing homes”

There are a few databases that don't require the use of quote marks such as Ovid Medline and other databases in the Ovid suite. The Database search tips provides details on phrase searching in key databases, or you can check the Help link in any database.

Subject headings (index terms)

Identify appropriate subject headings (index terms).

Many databases use subject headings to index content. These are selected from a controlled list and describe what the article is about. 

A comprehensive search strategy is often best achieved by using a combination of keywords and subject headings where possible.

In-depth knowledge of subject headings is not required for users to benefit from improved search performance using them in their searches.

Advantages of subject searching:

  • Helps locate articles that use synonyms, variant spellings, plurals
  • Search terms don’t have to appear in the title or abstract

Note: Subject headings are often unique to a particular database, so you will need to look for appropriate subject headings in each database you intend to use.

Subject headings are not available for every topic, and it is best to only select them if they relate closely to your area of interest.

MeSH (Medical Subject Headings)

The MeSH thesaurus provides standard terminology, imposing uniformity and consistency on the indexing of biomedical literature. In Pubmed/Medline each record is tagged with  MeSH  (Medical Subject Headings).

The MeSH vocabulary includes:

  • Represent concepts found in the biomedical literature
  • Some headings are commonly considered for every article (eg. Species (including humans), Sex, Age groups (for humans), Historical time periods)
  • attached to MeSH headings to describe a specific aspect of a concept
  • describe the type of publication being indexed; i.e., what the item is, not what the article is about (eg. Letter, Review, Randomized Controlled Trial)
  • Terms in a separate thesaurus, primarily substance terms

Create a 'gold set'

It is useful to build a ‘sample set’ or ‘gold set’ of relevant references before you develop your search strategy..

Sources for a 'gold set' may include:

  • key papers recommended by subject experts or supervisors
  • citation searching - looking at a reference list to see who has been cited, or using a citation database (eg. Scopus, Web of Science) to see who has cited a known relevant article
  • results of preliminary scoping searches.

The papers in your 'gold set' can then be used to help you identify relevant search terms

  • Look up your 'gold set' articles in a database that you will use for your literature review. For the articles indexed in the database, look at the records to see what keywords and/or subject headings are listed.

The 'gold set' will also provide a means of testing your search strategy

  • When an article in the sample set that is also indexed in the database is not retrieved, your search strategy can be revised in order to include it (see what concepts or keywords can be incorporated into your search strategy so that the article is retrieved).
  • If your search strategy is retrieving a lot of irrelevant results, look at the irrelevant records to determine why they are being retrieved. What keywords or subject headings are causing them to appear? Can you change these without losing any relevant articles from your results?
  • Information on the process of testing your search strategy using a gold set can be found in the systematic review guide

Example search strategy

A search strategy is the planned and structured organisation of terms used to search a database.

An example of a search strategy incorporating all three concepts, that could be applied to different databases is shown below:

screenshot of search strategy entered into a database Advanced search screen

You will use a combination of search operators to construct a search strategy, so it’s important to keep your concepts grouped together correctly. This can be done with parentheses (round brackets), or by searching for each concept separately or on a separate line.

The above search strategy in a nested format (combined into a single line using parentheses) would look like:

("infection control*" OR "infection prevention") AND ("methicillin resistant staphylococcus aureus" OR "meticillin resistant staphylococcus aureus" OR MRSA) AND ( "aged care home*" OR "nursing home*")

  • << Previous: Search strategies - Health/Medical topic example
  • Next: Keyword search activity >>

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Ten Simple Rules for Writing a Literature Review

Marco pautasso.

1 Centre for Functional and Evolutionary Ecology (CEFE), CNRS, Montpellier, France

2 Centre for Biodiversity Synthesis and Analysis (CESAB), FRB, Aix-en-Provence, France

Literature reviews are in great demand in most scientific fields. Their need stems from the ever-increasing output of scientific publications [1] . For example, compared to 1991, in 2008 three, eight, and forty times more papers were indexed in Web of Science on malaria, obesity, and biodiversity, respectively [2] . Given such mountains of papers, scientists cannot be expected to examine in detail every single new paper relevant to their interests [3] . Thus, it is both advantageous and necessary to rely on regular summaries of the recent literature. Although recognition for scientists mainly comes from primary research, timely literature reviews can lead to new synthetic insights and are often widely read [4] . For such summaries to be useful, however, they need to be compiled in a professional way [5] .

When starting from scratch, reviewing the literature can require a titanic amount of work. That is why researchers who have spent their career working on a certain research issue are in a perfect position to review that literature. Some graduate schools are now offering courses in reviewing the literature, given that most research students start their project by producing an overview of what has already been done on their research issue [6] . However, it is likely that most scientists have not thought in detail about how to approach and carry out a literature review.

Reviewing the literature requires the ability to juggle multiple tasks, from finding and evaluating relevant material to synthesising information from various sources, from critical thinking to paraphrasing, evaluating, and citation skills [7] . In this contribution, I share ten simple rules I learned working on about 25 literature reviews as a PhD and postdoctoral student. Ideas and insights also come from discussions with coauthors and colleagues, as well as feedback from reviewers and editors.

Rule 1: Define a Topic and Audience

How to choose which topic to review? There are so many issues in contemporary science that you could spend a lifetime of attending conferences and reading the literature just pondering what to review. On the one hand, if you take several years to choose, several other people may have had the same idea in the meantime. On the other hand, only a well-considered topic is likely to lead to a brilliant literature review [8] . The topic must at least be:

  • interesting to you (ideally, you should have come across a series of recent papers related to your line of work that call for a critical summary),
  • an important aspect of the field (so that many readers will be interested in the review and there will be enough material to write it), and
  • a well-defined issue (otherwise you could potentially include thousands of publications, which would make the review unhelpful).

Ideas for potential reviews may come from papers providing lists of key research questions to be answered [9] , but also from serendipitous moments during desultory reading and discussions. In addition to choosing your topic, you should also select a target audience. In many cases, the topic (e.g., web services in computational biology) will automatically define an audience (e.g., computational biologists), but that same topic may also be of interest to neighbouring fields (e.g., computer science, biology, etc.).

Rule 2: Search and Re-search the Literature

After having chosen your topic and audience, start by checking the literature and downloading relevant papers. Five pieces of advice here:

  • keep track of the search items you use (so that your search can be replicated [10] ),
  • keep a list of papers whose pdfs you cannot access immediately (so as to retrieve them later with alternative strategies),
  • use a paper management system (e.g., Mendeley, Papers, Qiqqa, Sente),
  • define early in the process some criteria for exclusion of irrelevant papers (these criteria can then be described in the review to help define its scope), and
  • do not just look for research papers in the area you wish to review, but also seek previous reviews.

The chances are high that someone will already have published a literature review ( Figure 1 ), if not exactly on the issue you are planning to tackle, at least on a related topic. If there are already a few or several reviews of the literature on your issue, my advice is not to give up, but to carry on with your own literature review,

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Object name is pcbi.1003149.g001.jpg

The bottom-right situation (many literature reviews but few research papers) is not just a theoretical situation; it applies, for example, to the study of the impacts of climate change on plant diseases, where there appear to be more literature reviews than research studies [33] .

  • discussing in your review the approaches, limitations, and conclusions of past reviews,
  • trying to find a new angle that has not been covered adequately in the previous reviews, and
  • incorporating new material that has inevitably accumulated since their appearance.

When searching the literature for pertinent papers and reviews, the usual rules apply:

  • be thorough,
  • use different keywords and database sources (e.g., DBLP, Google Scholar, ISI Proceedings, JSTOR Search, Medline, Scopus, Web of Science), and
  • look at who has cited past relevant papers and book chapters.

Rule 3: Take Notes While Reading

If you read the papers first, and only afterwards start writing the review, you will need a very good memory to remember who wrote what, and what your impressions and associations were while reading each single paper. My advice is, while reading, to start writing down interesting pieces of information, insights about how to organize the review, and thoughts on what to write. This way, by the time you have read the literature you selected, you will already have a rough draft of the review.

Of course, this draft will still need much rewriting, restructuring, and rethinking to obtain a text with a coherent argument [11] , but you will have avoided the danger posed by staring at a blank document. Be careful when taking notes to use quotation marks if you are provisionally copying verbatim from the literature. It is advisable then to reformulate such quotes with your own words in the final draft. It is important to be careful in noting the references already at this stage, so as to avoid misattributions. Using referencing software from the very beginning of your endeavour will save you time.

Rule 4: Choose the Type of Review You Wish to Write

After having taken notes while reading the literature, you will have a rough idea of the amount of material available for the review. This is probably a good time to decide whether to go for a mini- or a full review. Some journals are now favouring the publication of rather short reviews focusing on the last few years, with a limit on the number of words and citations. A mini-review is not necessarily a minor review: it may well attract more attention from busy readers, although it will inevitably simplify some issues and leave out some relevant material due to space limitations. A full review will have the advantage of more freedom to cover in detail the complexities of a particular scientific development, but may then be left in the pile of the very important papers “to be read” by readers with little time to spare for major monographs.

There is probably a continuum between mini- and full reviews. The same point applies to the dichotomy of descriptive vs. integrative reviews. While descriptive reviews focus on the methodology, findings, and interpretation of each reviewed study, integrative reviews attempt to find common ideas and concepts from the reviewed material [12] . A similar distinction exists between narrative and systematic reviews: while narrative reviews are qualitative, systematic reviews attempt to test a hypothesis based on the published evidence, which is gathered using a predefined protocol to reduce bias [13] , [14] . When systematic reviews analyse quantitative results in a quantitative way, they become meta-analyses. The choice between different review types will have to be made on a case-by-case basis, depending not just on the nature of the material found and the preferences of the target journal(s), but also on the time available to write the review and the number of coauthors [15] .

Rule 5: Keep the Review Focused, but Make It of Broad Interest

Whether your plan is to write a mini- or a full review, it is good advice to keep it focused 16 , 17 . Including material just for the sake of it can easily lead to reviews that are trying to do too many things at once. The need to keep a review focused can be problematic for interdisciplinary reviews, where the aim is to bridge the gap between fields [18] . If you are writing a review on, for example, how epidemiological approaches are used in modelling the spread of ideas, you may be inclined to include material from both parent fields, epidemiology and the study of cultural diffusion. This may be necessary to some extent, but in this case a focused review would only deal in detail with those studies at the interface between epidemiology and the spread of ideas.

While focus is an important feature of a successful review, this requirement has to be balanced with the need to make the review relevant to a broad audience. This square may be circled by discussing the wider implications of the reviewed topic for other disciplines.

Rule 6: Be Critical and Consistent

Reviewing the literature is not stamp collecting. A good review does not just summarize the literature, but discusses it critically, identifies methodological problems, and points out research gaps [19] . After having read a review of the literature, a reader should have a rough idea of:

  • the major achievements in the reviewed field,
  • the main areas of debate, and
  • the outstanding research questions.

It is challenging to achieve a successful review on all these fronts. A solution can be to involve a set of complementary coauthors: some people are excellent at mapping what has been achieved, some others are very good at identifying dark clouds on the horizon, and some have instead a knack at predicting where solutions are going to come from. If your journal club has exactly this sort of team, then you should definitely write a review of the literature! In addition to critical thinking, a literature review needs consistency, for example in the choice of passive vs. active voice and present vs. past tense.

Rule 7: Find a Logical Structure

Like a well-baked cake, a good review has a number of telling features: it is worth the reader's time, timely, systematic, well written, focused, and critical. It also needs a good structure. With reviews, the usual subdivision of research papers into introduction, methods, results, and discussion does not work or is rarely used. However, a general introduction of the context and, toward the end, a recapitulation of the main points covered and take-home messages make sense also in the case of reviews. For systematic reviews, there is a trend towards including information about how the literature was searched (database, keywords, time limits) [20] .

How can you organize the flow of the main body of the review so that the reader will be drawn into and guided through it? It is generally helpful to draw a conceptual scheme of the review, e.g., with mind-mapping techniques. Such diagrams can help recognize a logical way to order and link the various sections of a review [21] . This is the case not just at the writing stage, but also for readers if the diagram is included in the review as a figure. A careful selection of diagrams and figures relevant to the reviewed topic can be very helpful to structure the text too [22] .

Rule 8: Make Use of Feedback

Reviews of the literature are normally peer-reviewed in the same way as research papers, and rightly so [23] . As a rule, incorporating feedback from reviewers greatly helps improve a review draft. Having read the review with a fresh mind, reviewers may spot inaccuracies, inconsistencies, and ambiguities that had not been noticed by the writers due to rereading the typescript too many times. It is however advisable to reread the draft one more time before submission, as a last-minute correction of typos, leaps, and muddled sentences may enable the reviewers to focus on providing advice on the content rather than the form.

Feedback is vital to writing a good review, and should be sought from a variety of colleagues, so as to obtain a diversity of views on the draft. This may lead in some cases to conflicting views on the merits of the paper, and on how to improve it, but such a situation is better than the absence of feedback. A diversity of feedback perspectives on a literature review can help identify where the consensus view stands in the landscape of the current scientific understanding of an issue [24] .

Rule 9: Include Your Own Relevant Research, but Be Objective

In many cases, reviewers of the literature will have published studies relevant to the review they are writing. This could create a conflict of interest: how can reviewers report objectively on their own work [25] ? Some scientists may be overly enthusiastic about what they have published, and thus risk giving too much importance to their own findings in the review. However, bias could also occur in the other direction: some scientists may be unduly dismissive of their own achievements, so that they will tend to downplay their contribution (if any) to a field when reviewing it.

In general, a review of the literature should neither be a public relations brochure nor an exercise in competitive self-denial. If a reviewer is up to the job of producing a well-organized and methodical review, which flows well and provides a service to the readership, then it should be possible to be objective in reviewing one's own relevant findings. In reviews written by multiple authors, this may be achieved by assigning the review of the results of a coauthor to different coauthors.

Rule 10: Be Up-to-Date, but Do Not Forget Older Studies

Given the progressive acceleration in the publication of scientific papers, today's reviews of the literature need awareness not just of the overall direction and achievements of a field of inquiry, but also of the latest studies, so as not to become out-of-date before they have been published. Ideally, a literature review should not identify as a major research gap an issue that has just been addressed in a series of papers in press (the same applies, of course, to older, overlooked studies (“sleeping beauties” [26] )). This implies that literature reviewers would do well to keep an eye on electronic lists of papers in press, given that it can take months before these appear in scientific databases. Some reviews declare that they have scanned the literature up to a certain point in time, but given that peer review can be a rather lengthy process, a full search for newly appeared literature at the revision stage may be worthwhile. Assessing the contribution of papers that have just appeared is particularly challenging, because there is little perspective with which to gauge their significance and impact on further research and society.

Inevitably, new papers on the reviewed topic (including independently written literature reviews) will appear from all quarters after the review has been published, so that there may soon be the need for an updated review. But this is the nature of science [27] – [32] . I wish everybody good luck with writing a review of the literature.


Many thanks to M. Barbosa, K. Dehnen-Schmutz, T. Döring, D. Fontaneto, M. Garbelotto, O. Holdenrieder, M. Jeger, D. Lonsdale, A. MacLeod, P. Mills, M. Moslonka-Lefebvre, G. Stancanelli, P. Weisberg, and X. Xu for insights and discussions, and to P. Bourne, T. Matoni, and D. Smith for helpful comments on a previous draft.

Funding Statement

This work was funded by the French Foundation for Research on Biodiversity (FRB) through its Centre for Synthesis and Analysis of Biodiversity data (CESAB), as part of the NETSEED research project. The funders had no role in the preparation of the manuscript.

  • Library Guides
  • Literature Reviews
  • Writing the Review

Literature Reviews: Writing the Review

Outline of review sections.

research strategy literature review

Your Literature Review should not be a summary and evaluation of each article, one after the other. Your sources should be integrated together to create a narrative on your topic.

Consider the following ways to organize your review:

  • By themes, variables, or issues
  • By varying perspectives regarding a topic of controversy
  • Chronologically, to show how the topic and research have developed over time

Use an outline to organize your sources and ideas in a logical sequence. Identify main points and subpoints, and consider the flow of your review. Outlines can be revised as your ideas develop. They help guide your readers through your ideas and show the hierarchy of your thoughts. What do your readers need to understand first? Where might certain studies fit most naturally? These are the kinds of questions that an outline can clarify.

An example outline for a Literature Review might look like this:


  • Background information on the topic & definitions
  • Purpose of the literature review
  • Scope and limitations of the review (what is included /excluded)
  • Historical background 
  • Overview of the existing research on the topic
  • Principle question being asked
  • Organization of the literature into categories or themes
  • Evaluation of the strengths and weaknesses of each study
  • Combining the findings from multiple sources to identify patterns and trends
  • Insight into the relationship between your central topic and a larger area of study
  • Development of a new research question or hypothesis
  • Summary of the key points and findings in the literature
  • Discussion of gaps in the existing knowledge
  • Implications for future research

Strategies for Writing

Annotated bibliography.

An annotated bibliography collects short descriptions of each source in one place. After you have read each source carefully, set aside some time to write a brief summary. Your summary might be simply informative (e.g. identify the main argument/hypothesis, methods, major findings, and/or conclusions), or it might be evaluative (e.g. state why the source is interesting or useful for your review, or why it is not).

This method is more narrative than the Literature Matrix talked about on the Documenting Your Search page.

Taking the time to write short informative and/or evaluative summaries of your sources while you are researching can help you transition into the drafting stage later on. By making a record of your sources’ contents and your reactions to them, you make it less likely that you will need to go back and re-read many sources while drafting, and you might also start to gain a clearer idea of the overarching shape of your review.


As you conduct your research, you will likely read many sources that model the same kind of literature review that you are researching and writing. While your original intent in reading those sources is likely to learn from the studies’ content (e.g. their results and discussion), it will benefit you to re-read these articles rhetorically.

Reading rhetorically means paying attention to how a text is written—how it has been structured, how it presents its claims and analyses, how it employs transitional words and phrases to move from one idea to the next. You might also pay attention to an author’s stylistic choices, like the use of first-person pronouns, active and passive voice, or technical terminology.

See  Finding Example Literature Reviews on the Developing a Research Question page for tips on finding reviews relevant to your topic.


Creating a mind-map is a form of brainstorming that lets you visualize how your ideas function and relate. Draw the diagram freehand or download software that lets you easily manipulate and group text, images, and shapes ( Coggle ,  FreeMind , MindMaple ).

Write down a central idea, then identify associated concepts, features, or questions around that idea. Make lines attaching various ideas, or arrows to signify directional relationships. Use different shapes, sizes, or colors to indicate commonalities, sequences, or relative importance.

research strategy literature review

This drafting technique allows you to generate ideas while thinking visually about how they function together. As you follow lines of thought, you can see which ideas can be connected, where certain pathways lead, and what the scope of your project might be. By drawing out a mind-map you may be able to see what elements of your review are underdeveloped and will benefit from more focused attention.



Thanks to Librarian Jamie Niehof at the University of Michigan for providing permission to reuse and remix this Literature Reviews guide.

Avoiding Bias

Reporting bias.

This occurs when you are summarizing the literature in an unbalanced, inconsistent or distorted way . 

Ways to avoid:

  • look for literature that supports multiple perspectives, viewpoints or theories 
  • ask multiple people to review your writing for bias
  • Last Updated: Apr 9, 2024 3:50 PM
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CPS Online Library Research Guide (UNH Manchester Library): Create a Literature Review

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What is a literature review?

A literature review discusses published information in a particular subject area, and sometimes information in a particular subject area within a certain time period.

A literature review can be just a simple summary of the sources, but it usually has an organizational pattern and combines both summary and synthesis. A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information. It might give a new interpretation of old material or combine new with old interpretations. Or it might trace the intellectual progression of the field, including major debates. And depending on the situation, the literature review may evaluate the sources and advise the reader on the most pertinent or relevant.

But how is a literature review different from an academic research paper?

The main focus of an academic research paper is to develop a new argument, and a research paper is likely to contain a literature review as one of its parts. In a research paper, you use the literature as a foundation and as support for a new insight that you contribute. The focus of a literature review, however, is to summarize and synthesize the arguments and ideas of others without adding new contributions.

Why do we write literature reviews?

Literature reviews provide you with a handy guide to a particular topic. If you have limited time to conduct research, literature reviews can give you an overview or act as a stepping stone. For professionals, they are useful reports that keep them up to date with what is current in the field. For scholars, the depth and breadth of the literature review emphasizes the credibility of the writer in his or her field. Literature reviews also provide a solid background for a research paper’s investigation. Comprehensive knowledge of the literature of the field is essential to most research papers.

Strategies for writing the literature review

Find a focus.

A literature review, like a term paper, is usually organized around ideas, not the sources themselves as an annotated bibliography would be organized. This means that you will not just simply list your sources and go into detail about each one of them, one at a time. No. As you read widely but selectively in your topic area, consider instead what themes or issues connect your sources together. Do they present one or different solutions? Is there an aspect of the field that is missing? How well do they present the material and do they portray it according to an appropriate theory? Do they reveal a trend in the field? A raging debate? Pick one of these themes to focus the organization of your review.

Convey it to your reader

A literature review may not have a traditional thesis statement (one that makes an argument), but you do need to tell readers what to expect. Try writing a simple statement that lets the reader know what is your main organizing principle. Here are a couple of examples:

The current trend in treatment for congestive heart failure combines surgery and medicine.

More and more cultural studies scholars are accepting popular media as a subject worthy of academic consideration.

Consider organization

You’ve got a focus, and you’ve stated it clearly and directly. Now what is the most effective way of presenting the information? What are the most important topics, subtopics, etc ., that your review needs to include? And in what order should you present them? Develop an organization for your review at both a global and local level:

First, cover the basic categories

Just like most academic papers, literature reviews are likely to contain at least three basic elements: an introduction or background information section; the body of the review containing the discussion of sources; and, finally, a conclusion and/or recommendations section to end the paper. The following provides a brief description of the content of each:

  • Introduction: Gives a quick idea of the topic of the literature review, such as the central theme or organizational pattern.
  • Body: Contains your discussion of sources and is organized either chronologically, thematically, or methodologically (see below for more information on each).
  • Conclusions/Recommendations: Discuss what you have drawn from reviewing literature so far. Where might the discussion proceed?

Organizing the body

Once you have the basic categories in place, then you must consider how you will present the sources themselves within the body of your paper. Create an organizational method to focus this section even further.

To help you come up with an overall organizational framework for your review, consider the following scenario:

You’ve decided to focus your literature review on materials dealing with sperm whales. This is because you’ve just finished reading Moby Dick, and you wonder if that whale’s portrayal is really real. You start with some articles about the physiology of sperm whales in biology journals written in the 1980’s. But these articles refer to some British biological studies performed on whales in the early 18th century. So you check those out. Then you look up a book written in 1968 with information on how sperm whales have been portrayed in other forms of art, such as in Alaskan poetry, in French painting, or on whale bone, as the whale hunters in the late 19th century used to do. This makes you wonder about American whaling methods during the time portrayed in Moby Dick, so you find some academic articles published in the last five years on how accurately Herman Melville portrayed the whaling scene in his novel.

Now consider some typical ways of organizing the sources into a review:

  • Chronological: If your review follows the chronological method, you could write about the materials above according to when they were published. For instance, first you would talk about the British biological studies of the 18th century, then about Moby Dick, published in 1851, then the book on sperm whales in other art (1968), and finally the biology articles (1980s) and the recent articles on American whaling of the 19th century. But there is relatively no continuity among subjects here. And notice that even though the sources on sperm whales in other art and on American whaling are written recently, they are about other subjects/objects that were created much earlier. Thus, the review loses its chronological focus.
  • By publication: Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on biological studies of sperm whales if the progression revealed a change in dissection practices of the researchers who wrote and/or conducted the studies.
  • By trend: A better way to organize the above sources chronologically is to examine the sources under another trend, such as the history of whaling. Then your review would have subsections according to eras within this period. For instance, the review might examine whaling from pre-1600-1699, 1700-1799, and 1800-1899. Under this method, you would combine the recent studies on American whaling in the 19th century with Moby Dick itself in the 1800-1899 category, even though the authors wrote a century apart.
  • Thematic: Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For instance, the sperm whale review could focus on the development of the harpoon for whale hunting. While the study focuses on one topic, harpoon technology, it will still be organized chronologically. The only difference here between a “chronological” and a “thematic” approach is what is emphasized the most: the development of the harpoon or the harpoon technology.But more authentic thematic reviews tend to break away from chronological order. For instance, a thematic review of material on sperm whales might examine how they are portrayed as “evil” in cultural documents. The subsections might include how they are personified, how their proportions are exaggerated, and their behaviors misunderstood. A review organized in this manner would shift between time periods within each section according to the point made.
  • Methodological: A methodological approach differs from the two above in that the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the “methods” of the researcher or writer. For the sperm whale project, one methodological approach would be to look at cultural differences between the portrayal of whales in American, British, and French art work. Or the review might focus on the economic impact of whaling on a community. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed. Once you’ve decided on the organizational method for the body of the review, the sections you need to include in the paper should be easy to figure out. They should arise out of your organizational strategy. In other words, a chronological review would have subsections for each vital time period. A thematic review would have subtopics based upon factors that relate to the theme or issue.

Sometimes, though, you might need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. Put in only what is necessary. Here are a few other sections you might want to consider:

  • Current Situation: Information necessary to understand the topic or focus of the literature review.
  • History: The chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
  • Methods and/or Standards: The criteria you used to select the sources in your literature review or the way in which you present your information. For instance, you might explain that your review includes only peer-reviewed articles and journals.

Questions for Further Research: What questions about the field has the review sparked? How will you further your research as a result of the review?


"Create a Literature Review" is derivative of Literature Reviews by The Writing Center, University of North Carolina at Chapel Hill licensed Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License .

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  • Last Updated: Apr 9, 2024 2:30 PM
  • URL: https://libraryguides.unh.edu/CPSonlineLibraryResearch

Literature reviews as a research strategy

  • PMID: 23012244
  • DOI: 10.1177/1059840512458666

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Retirement planning – a systematic review of literature and future research directions

  • Published: 28 October 2023

Cite this article

  • Kavita Karan Ingale   ORCID: orcid.org/0000-0003-3570-4211 1 &
  • Ratna Achuta Paluri 2  

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Rising life expectancy and an aging population across nations are leading to an increased need for long-term financial savings and a focus on the financial well-being of retired individuals amidst changing policy framework. This study is a systematic review based on a scientific way of producing high-quality evidence based on 191 articles from the Scopus and Web of Science databases. It adopts the Theory, Context, Characteristics, and Method (TCCM) framework to analyze literature. This study provides collective insights into financial decision-making for retirement savings and identifies constructs for operationalizing and measuring financial behavior for retirement planning. Further, it indicates the need for an interdisciplinary approach. Though cognitive areas were studied extensively, the non-cognitive areas received little attention. Qualitative research design is gaining prominence in research over other methods, with the sparse application of mixed methods design. The study’s TCCM framework explicates several areas for further research. Furthermore, it guides the practice and policy by integrating empirical evidence and concomitant findings. Coherent synthesis of the extant literature reconciles the highly fragmented field of retirement planning. No research reports prospective areas for further analysis based on the TCCM framework on retirement planning, which highlights the uniqueness of the study.

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The impact of virtual reality on student engagement in the classroom–a critical review of the literature.

Xiao Ping Lin&#x;

  • 1 Faculty of Education, Silpakorn University, Nakhon Pathom, Thailand
  • 2 Melbourne Graduate School of Education, The University of Melbourne, Melbourne, VIC, Australia
  • 3 Graduate Department, Xi’an Physical Education University, Xi’an, China
  • 4 College of Commerce and Tourism, Hunan Vocational College for Nationalities, Yueyang, China
  • 5 Graduate Department, Sehan University, Yeongam County, Republic of Korea

Objective: The purpose of this review is to identify the impact of virtual reality (VR) technology on student engagement, specifically cognitive engagement, behavioral engagement, and affective engagement.

Methods: A comprehensive search of databases such as Google, Scopus, and Elsevier was conducted to identify English-language articles related to VR and classroom engagement for the period from 2014 to 2023. After systematic screening, 33 articles were finally reviewed.

Results: The use of VR in the classroom is expected to improve student engagement and learning outcomes, and is particularly effective for students with learning disabilities. However, introducing VR into middle school education poses several challenges, including difficulties in the education system to keep up with VR developments, increased demands on students’ digital literacy, and insufficient proficiency of teachers in using VR.

Conclusion: To effectively utilize VR to increase student engagement, we advocate for educational policymakers to provide training and technical support to teachers to ensure that they can fully master and integrate VR to increase student engagement and instructional effectiveness.


In recent years, virtual reality (VR) has emerged as a transformative technology in education, providing new avenues for immersive and interactive learning experiences ( Pottle, 2019 ). At its core, VR offers a departure from the tangible, allowing users to delve into an environment transcending conventional reality ( Brooks, 1999 ; Jeong et al., 2019 ). VR’s essence is captured in three pillars: presence, interactivity, and immersion ( Lee et al., 2017 ). Presence grants users access to previously unreachable 3D landscapes, facilitating a unique, experiential insight ( Poux et al., 2020 ). Interactivity kindles user curiosity, enabling dynamic engagements within the virtual milieu ( Steuer et al. 1995 ; Huvila, 2013 ; Song et al., 2023 ). Immersion pushes the boundaries of conventional experiences, reviving or manifesting phenomena outside the realm of everyday life ( Sanchez-Vives and Slater, 2005 ; Poux et al., 2020 ).

The introduction of VR in education might increase student engagement, which is closely related to the cognitive, behavioral, and affective dimensions of the engagement model ( Wang and Degol, 2014 ). Cognitive engagement underscores the depth of students’ attention, comprehension, and retention ( Wang and Degol, 2014 ). Behavioral engagement is observable, characterized by consistent attendance and active classroom participation ( Wang and Degol, 2014 ). Affective engagement delves into the emotional realm, encompassing motivation, passion, and learning efficacy ( Wang and Degol, 2014 ).

Existing literature emphasizes the importance of virtual reality technology in promoting full student engagement in cognitive, behavioral, and affective dimensions, and states that the application of virtual reality technology in education has become a trend ( Mystakidis et al., 2021 ). Some literature shows that higher education institutions are increasingly adopting VR, with adoption rates as high as 46% at US universities and 96% at United Kingdom universities ( United Kingdom Authority, 2019 ; Agbo et al., 2021 ). In addition, the establishment of dedicated VR laboratories at leading universities such as Harvard University and Colorado State University underscores the commitment to using VR for educational innovation and advancement ( Reid, 1987 ; Leidner and Jarvenpaa, 1995 ). This literature shows that the widespread use of VR in education has attracted the attention of a growing number of researchers and educators, with a particular interest in the impact of VR in the classroom in terms of students’ cognitive, behavioral, and affective engagement.

It is worth noting that although existing literature begins to discuss the impact of VR on student engagement, there are still shortcomings in determining the impact of VR on various dimensions of student engagement, which may limit our overall understanding of the topic. Therefore, further discussion is needed to more specifically identify the impact of VR on the various dimensions of student engagement to gain a more comprehensive and concrete understanding. To accomplish this, this review is guided by the following three questions: (1) What are the positive impacts of VR in education? (2) What are the challenges of VR in education? (3) What interventions can address these challenges? With this in mind, the article will first discuss the positive impact of VR on students’ cognitive, behavioral, and affective engagement to help readers understand its potential in education. It will then discuss the challenges facing VR to make constructive recommendations to address the problems in education.

Searching strategy

In our methods, we used critical review. According to Grant and Booth (2009) “an effective critical review presents, analyses and synthesizes material from diverse sources”(p.93). Critical perspectives were used to assess the potential of VR in reforming educational practices and improving teaching and learning outcomes. The purpose of this article was to collect literature on the impact of VR on student engagement. Therefore, this article summarizes the previous studies as follows. First, information was obtained from Google, Scopus, and Elsevier databases: “virtual reality,” “cognitive engagement,” “affective engagement,” “behavioral engagement” and “learning outcomes.” The search was limited to articles published between January 2014 and December 2023 in English. The first search used all combinations of the above keywords and, after an initial review, produced 97 potentially relevant articles (Google: 92, Scopus: 3, Elsevier: 2).

In the second phase, secondary terms such as “affect,” “challenge,” and “education” were added, reducing the number of studies to 63 (Google:60, Scopus:1, Elsevier:2). Of these, 34 did not meet the criteria and were excluded. They were excluded because their target audience was teachers and did not discuss the impact of VR on student engagement from the student’s perspective. In the final stage, another 53 articles were excluded because they were repetitive and their purpose was to discuss either technology or engagement, or both. Finally, their full texts were reviewed to determine if their work fits the focus of this article 20 articles (Google: 17, Scopus: 1, Elsevier: 2) qualified for final review, covered a sample on the impact of VR on student engagement, and were included in the analysis.

Inclusion and exclusion criteria

To ensure the quality of the literature, we selected only peer-reviewed journal articles published in English in the last decade. The main purpose of this article was to review the impact of VR on student engagement. Therefore, we selected only review articles on the impact of VR on student engagement in educational settings. Articles that were not written in English did not discuss the impact on engagement from a student perspective, and were published beyond the previously established time and language were excluded. In addition, a selection of articles was identified and assessed by manually searching the references of articles related to the topic, of which 13 met the eligibility criteria. Therefore, 13 additional articles were added to the 20 identified. In total, 33 articles that met these eligibility criteria were included and reviewed here. Full-text versions of the articles were obtained, with each article being reviewed and confirmed as appropriate by the authors. Finally, to maximize transparency and traceability, we list the rationale and relevant evidence for all articles included (see Table 1 ). The process of article selection followed the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement ( Moher et al., 2009 ; see Figure 1 ). Figure 1 illustrates the process of article selection.


Table 1 . Publications reviewed in full text with reasons for inclusion or exclusion.


Figure 1 . PRISMA flow diagram for article selection.

The review found that the number of publications increased each year from 2014 to 2023, indicating the continued interest of researchers in exploring the impact of VR on student engagement. When reviewing the impact of VR on student engagement, Wang and Degol’s (2014) article had the most citations at 450, suggesting that the article had a strong impact in the area of student use of VR in the classroom. The majority of articles had only 10 or fewer citations, which may have indicated that these articles were relatively new or had less impact in the field. It was worth noting that more recently published articles, such as Rzanova et al. (2023) , did not have enough time to accumulate citations, so their impact on the field may not have been fully reflected in current citations.

To summarize, the differences in the number of citations for these articles highlighted their different levels of influence in the area of VR’s impact on student engagement. However, there were some limitations to the review methods. For example, some articles might not have fully reflected their impact on the field in the current citations due to their short time frames, which might have resulted in less comprehensive findings. Furthermore, the literature included was small, and in the future consideration would be given to expanding the search of literature and databases, such as PubMed and Web of Science databases, as well as expanding the search with keywords, such as “students’ attitudes toward VR.” In addition, the inclusion and exclusion criteria might have limited the generalizability of the results of the review, and therefore more caution was needed when generalizing the results of the review.

The positive impact of VR on education

This section will discuss the impact of VR on students’ cognitive, behavioral, and affective engagement participation. It is important in the field of education. Radianti et al. (2020) noted that student engagement in educational settings was critical to learning outcomes and classroom climate. Yuan and Wang (2021) further noted that the combined effects of cognitive, behavioral, and affective engagement could directly impact student learning outcomes and classroom contextual experiences. Therefore, a deeper understanding of the impact of VR on these three dimensions of engagement can provide valuable insights into educational practices and help educators better optimize classroom environments and teaching methods.

First, Papanastasiou et al. (2019) noted that VR immersive learning experiences promoted students’ cognitive engagement and aided in understanding complex and abstract knowledge. That is, through immersive learning, students can understand and remember what they have learned in greater depth and increase cognitive engagement. Pellas (2016) also found that VR encouraged students to learn through self-directed inquiry and move away from traditional teacher-centered instruction. Pellas (2016) further explained that, through VR scenario reenactments and simulations, students could engage in real-world unavailable learning experiences such as exploring historical sites and visiting distant planets. This means that such learning experiences enable students to explore knowledge in deeper and more varied ways, thus increasing cognitive engagement. Similarly, Maples-Keller et al. (2017) showed that VR was beneficial in engaging different types of students in learning, particularly for at-risk students, including those with learning difficulties, anxiety disorders, and other mental illnesses. VR provided personalized and adaptive learning environments that helped students improve cognitive engagement and achievement ( Maples-Keller et al., 2017 ). In summary, VR facilitates understanding of complex knowledge and promotes cognitive engagement for different types of students through immersive learning experiences and self-directed inquiry learning.

Secondly, Pirker and Dengel (2021) demonstrated that VR could promote student behavioral engagement. They discussed the potential of immersive VR in education through an in-depth analysis of 64 articles. They showed that “learning tasks in 3-D VLEs can foster intrinsic motivation for and engagement with the learning content” (p.77). Sun and Peng (2020) also suggested that by combining classical educational concepts with VR, such as Confucianism’s promotion of teaching for fun, students were better able to engage in learning activities. For example, Rzanova et al. (2023) found that the use of VR in the teaching of poetry to create the scenarios depicted in the verses enabled students to actively participate in classroom activities. Similarly, Freina and Ott (2015) also found that by simulating real school escape scenarios in VR, students could take on different roles to perform escape drills, and this sense of behavioral engagement can help students better master escape techniques and enhance safety awareness. These articles seem to echo that VR helps to enhance student behavioral engagement.

It is worth noting that there is debate about whether VR has a positive impact on student behavioral engagement. Proponents noted that students’ hands-on experience and exploration in virtual environments stimulated interest and behavioral engagement ( Wong et al., 2010 ; Allcoat and Von Mühlenen, 2018 ). This view suggests that VR provides an immersive learning experience that enhances students’ motivation and promotes deeper engagement in classroom activities. However, contrary findings exist, suggesting that the use of VR may have some negative effects. For example, students might have become addicted to the virtual world and neglected their real-life tasks and responsibilities, thus affecting their behavior in the classroom ( Cheng et al., 2015 ; Greenwald et al., 2018 ; Makransky et al., 2019 ). In addition, some other scholars noted that there might have been a gap between learning experiences in virtual environments and real-world learning experiences, which might have affected students’ ability to acquire and apply knowledge ( Makransky and Petersen, 2021 ). These conflicting results remind us that these complexities and diversities need to be taken into account when evaluating the role of VR technology in improving student engagement in the classroom.

Finally, scholars such as Wu et al. (2013) , Schutte and Stilinović (2017) , and Yuen et al. (2011) found that VR helped to promote student affective engagement. For example, Schutte and Stilinović (2017) found that contexts provided by VR for children with emotional impairments or disabilities taught them skills in communicating with people and managing their emotions, thus fostering empathy. This implies that VR may stimulate affective engagement. Wu et al. (2013) and Yuen et al. (2011) also found that VR provided opportunities for affective interaction, enabling students to interact with characters in the virtual environment. In language learning, for example, practicing through conversations with virtual characters could help students improve their oral expression ( Dhimolea et al., 2022 ). This means that affective interactions may increase students’ affective engagement with the learning content. Similarly, Misak (2018) noted that VR allowed students to role-play in virtual literature and experience the affective portrayed in the story. In other words, affective experiences may deepen students’ understanding of literary works and increase affective engagement. This literature seems to reflect that VR can promote student affective engagement.

In general, VR positively impacts students’ cognitive, behavioral, and affective engagement. In terms of cognitive engagement, VR can facilitate students’ cognitive engagement with learning materials and better understanding of abstract and complex knowledge by creating immersive situations. In terms of behavioral engagement, VR stimulates active student engagement and action through interactive learning. Although there is debate about whether VR has a positive impact on student behavioral engagement, literature has demonstrated the positive impact of VR on student behavioral engagement. In terms of affective engagement, VR promotes students’ emotional engagement by triggering affective resonance through affective experience and affective interaction. This full engagement helps students improve their learning and develop empathy.

The following section discusses the challenges faced when introducing VR in education. Through understanding these challenges, we can better understand the problems in the education system and make some constructive suggestions to help address them.

The challenge of VR in education

Despite the positive impact of VR on students’ cognitive, behavioral, and affective engagement, there are still two challenges to introducing VR into middle education, namely the difficulty of the educational system in keeping up with VR developments and the lack of teacher proficiency in VR use ( Islam et al., 2015 ; Zhong, 2017 ; Abich et al., 2021 ). For example, Islam et al. (2015) observed that the pace of technological advancement, including VR, outpaced the ability of the education system to adapt. This phenomenon is due to the slow reform of the education system, which takes time for the acceptance and adoption of emerging technologies ( Islam et al., 2015 ). To this end, the education sector may take longer to standardize the syllabus, resulting in students not having immediate access to VR ( Zhong, 2017 ). In other words, students may not have the opportunity to experience VR in the classroom until the education department completes the standardization process. Sahlberg (2016) further stated that while reform and standardization in the education sector took time, once VR and the education system evolved in tandem, students benefited from an education that matched the VR of the day.

Other scholars observed that VR education faced several challenges in developing digital literacy in students ( Aviram and Eshet-Alkalai, 2006 ; Sahlberg, 2016 ). According to Reddy et al. (2020) , “digital literacy is a set of skills required by 21st Century individuals to use digital tools to support the achievement of goals in their life situations” (p. 66). Digital literacy encompasses the assessment of digital technologies, critical thinking, and the ability to create and express oneself digitally ( Reddy et al., 2020 ). For example, Tsivitanidou et al. (2021) and Necci et al. (2015) emphasized the need for students to identify the differences between the results of simulation experiments and real experiments and to assess the reliability and accuracy of simulation experiments. In other words, students need to judge the plausibility of the results of simulation experiments and interpret and evaluate those results in real-world situations.

Similarly, Farmer and Farmer (2023) found that digital literacy required students to master VR painting and sculpting tools to create art. This involved learning to select appropriate colors and textures and creating three-dimensional effects with VR tools ( Skulmowski et al., 2021 ). Meanwhile, Andone et al. (2018) further noted that students also needed to learn to share and present their work to others in virtual reality. This observation seems to reflect the high demand for students’ creativity, technical skills, and expressive abilities when introducing VR into education. In sum, while the development of VR education benefits students’ learning in conjunction with VR, there are challenges to students’ digital literacy and the technological adaptability of the education system.

In addition, teachers’ lack of proficiency in the use of VR is another major challenge in introducing VR into middle education. For example, Abich et al. (2021) found that teachers might lack proficiency in the operation and application of VR, which might result in teachers not being able to fully utilize VR to supplement instruction. Jensen and Konradsen (2018) claimed that “for HMDs to become a relevant tool for instructors they must have the ability to produce and edit their content” (p.1525). This means that teachers need to spend time familiarizing themselves with HMDs and related software to create, edit, and customize content to meet their specific instructional needs. Similarly, Fransson et al. (2020) discussed the challenges of teachers operating VR equipment and software. They interviewed 28 teachers to understand teachers’ challenges with implementing helmet display VR in educational settings. Fransson et al. (2020) indicated that there might be a technological threshold and learning curve for teachers in controlling and operating VR devices, which might affect the effective use of VR for teaching and learning.

While teachers may lack familiarity with VR, there are solutions to this challenge. For example, Alfalah (2018) noted that proper training and support could help teachers make the most of VR to supplement instruction. That is, teacher training can provide teachers with the technical knowledge and operational skills they need to familiarize themselves with how VR equipment and software work. To this end, Alfalah (2018) found the impact of providing teachers with VR training in schools. They used a quantitative approach by distributing a questionnaire online to 30 IT teachers. Alfalah (2018) indicated that “technology training may be maximized for the integration of VR technology” (P.2634). This finding seems to reflect that proper teacher training and support can be effective in helping teachers overcome the operational and application of VR technology’s difficulties.

In sum, prior literature has shown that introducing VR into middle school education faces several challenges. First, the rapid development of technology makes the educational system keep up with VR, resulting in a disconnect between the educational curriculum and VR. Second, there may be a lack of proficiency in students’ digital literacy and teachers’ handling and application of VR. However, these challenges are not insurmountable. With proper training and support, teachers can make full use of VR to supplement their teaching and learning to realize the potential of VR in education. It is worth noting that through the literature we have found that in practice, due to the rapid development of technology and the limitations of the educational system, achieving a complete balance may take some time and effort. Therefore, considering how to address the gap between the speed of VR development and the education system to better integrate and apply VR in education makes sense.

This article describes the impact of VR on student cognitive, behavioral, and affective engagement and the challenges posed by VR education. The literature review finds that using VR in the classroom can positively impact student engagement and learning outcomes. An interesting finding is that VR can be a promising tool for providing education to students with learning disabilities. For example, the previous literature review section describes how for students with learning difficulties, anxiety disorders, and other mental illnesses, VR can provide personalized and adaptive learning environments that can help students improve cognitive engagement and academic performance. And, for children with emotional disorders or disabilities, VR provides contexts that can teach them skills for communicating with others and managing their emotions, thereby developing empathy and stimulating affective engagement.

However, the potential problems with incorporating VR in middle education are the difficulty of the education system in keeping up with VR developments, the higher demands of student digital literacy, and the lack of teacher proficiency in the use of VR. These challenges require educational policymakers to provide training and technical support to teachers to ensure that they can fully master and integrate VR to improve student engagement and teaching effectiveness.

Author contributions

XL: Writing – original draft, Writing – review & editing. BL: Conceptualization, Writing – original draft, Writing – review & editing. ZNY: Writing – original draft, Writing – review & editing. ZY: Funding acquisition, Supervision, Writing – original draft, Writing – review & editing. MZ: Funding acquisition, Writing – original draft, Writing – review & editing, Supervision.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by the General Topics of China’s Hunan Province Social Science Achievement Evaluation Committee Fund [Grant no. XSP2023JYC123].


We are deeply appreciative of the editors and reviewers of this journal for their unwavering dedication and contributions that have shaped the publication of this article. Their constructive feedback and invaluable insights were instrumental in bringing this piece to fruition. We extend our heartfelt thanks to the readers with a keen interest in virtual reality technology. It is our sincere hope that this article will inspire enriched discussions within the academic community about the potential and nuances of using virtual reality in educational contexts.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: virtual reality technology, cognitive engagement, affective engagement, behavioral engagement, learning outcomes

Citation: Lin XP, Li BB, Yao ZN, Yang Z and Zhang M (2024) The impact of virtual reality on student engagement in the classroom–a critical review of the literature. Front. Psychol . 15:1360574. doi: 10.3389/fpsyg.2024.1360574

Received: 23 December 2023; Accepted: 22 March 2024; Published: 10 April 2024.

Reviewed by:

Copyright © 2024 Lin, Li, Yao, Yang and Zhang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Zhi Yang, [email protected] ; Mingshu Zhang, [email protected]

† These authors have contributed equally to this work and share first authorship

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

  • Open access
  • Published: 05 September 2022

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

  • Ashlea Hambleton 1 ,
  • Genevieve Pepin 2 ,
  • Anvi Le 3 ,
  • Danielle Maloney 1 , 4 ,
  • National Eating Disorder Research Consortium ,
  • Stephen Touyz 1 , 4 &
  • Sarah Maguire 1 , 4  

Journal of Eating Disorders volume  10 , Article number:  132 ( 2022 ) Cite this article

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Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021–2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.


This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

Plain English Summary

The mortality rate of eating disorders is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. Further, individuals with eating disorders often meet the diagnostic criteria of at least one comorbid psychiatric or medical disorder, that is, the individual simultaneously experiences both an ED and at least one other condition. This has significant consequences for researchers and health care providers – medical and psychiatric comorbidities impact ED symptoms and treatment effectiveness. The current review is part of a larger Rapid Review series conducted to inform the development of Australia’s National Eating Disorders Research and Translation Strategy 2021–2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policymaking and address urgent health concerns. The Rapid Review synthesises the current evidence base and identifies gaps in eating disorder research and care. This paper gives a critical overview of the scientific literature relating to the psychiatric and medical comorbidities of eating disorders. It covers recent literature regarding psychiatric comorbidities including anxiety disorders, mood disorders, substance use disorders, trauma and personality disorders and neurodevelopmental disorders. Further, the review discusses the impact and associations between EDs and medical comorbidities, some of which precede the eating disorder, occur alongside, or as a consequence of the eating disorder.


Eating Disorders (EDs) are often severe, complex, life-threatening illnesses with significant physiological and psychiatric impacts. EDs impact individuals across the entire lifespan, affecting all age groups (although most often they emerge in childhood and adolescence), genders, socioeconomic groups and cultures [ 1 ]. EDs have some of the highest mortality rates of all psychiatric illnesses and carry a significant personal, interpersonal, social and economic burdens [ 2 , 3 ].

Adding to the innate complexity of EDs, it is not uncommon for people living with an ED to experience associated problems such as psychological, social, and functional limitations [ 2 ] in addition to psychiatric and medical comorbidities [ 4 , 5 , 6 ]. Comorbidity is defined as conditions or illnesses that occur concurrently to the ED. Evidence suggests that between 55 and 95% of people diagnosed with an ED will also experience a comorbid psychiatric disorder in their lifetime [ 4 , 6 ]. Identifying psychiatric comorbidities is essential because of their potential impact on the severity of ED symptomatology, the individual’s distress and treatment effectiveness [ 7 , 8 ].

The mortality rate of EDs is significantly higher than the general population, with the highest occurring in Anorexia Nervosa (AN) due to impacts on the cardiovascular system [ 9 ] and suicide. [ 10 ] Mortality rates are also heightened in Bulimia Nervosa (BN) and Other Specified Feeding and Eating Disorder (OSFED) [ 11 ]. Suicide rates are elevated across the ED spectrum, and higher rates are observed in patients with a comorbid psychiatric disorder [ 10 , 12 ]. Of concern, the proportion of people with an ED not accessing treatment is estimated to be as high as 75% [ 13 ], potentially a consequence of comorbidities which impact on motivation, the ability to schedule appointments or require clinical prioritisation (i.e., self-harm or suicidal behaviours) [ 14 ]. Further, for many of those diagnosed with an ED who access treatment, recovery is a lengthy process. A longitudinal study found approximately two-thirds of participants with AN or BN had recovered by 22 years follow-up [ 15 ]. Although recovery occurred earlier for those with BN, illness duration was lengthy for both groups with quality of life and physical health impacts [ 15 ]. Further, less is known regarding the illness trajectory for those who do not receive treatment.

Medical comorbidities associated with EDs can range from mild to severe and life-threatening, with complications observed across all body systems, including the cardiac, metabolic and gastrointestinal, and reproductive systems [ 5 ]. These comorbidities and complications can place people at increased risk of medical instability and death [ 5 ]. Therefore, understanding how co-occurring medical comorbidities and complications impact EDs is critical to treatment and recovery.

In addition to ED-associated medical comorbidities, EDs often present alongside other psychiatric conditions. Psychiatric comorbidities in people with EDs are associated with higher health system costs, emergency department presentations and admissions [ 16 ]. Comorbidities may precede the onset of the ED, be co-occurring, or result from symptoms and behaviours associated with the ED [ 17 , 18 ]. Individuals with an ED, their carers and care providers often face a complex and important dilemma; the individual with an ED requires treatment for their ED but also for their psychiatric comorbidities, and it can be difficult for treatment providers to determine which is the clinical priority [ 19 ]. This is further complicated by the fact that EDs and comorbidities may have a reciprocal relationship, whereby the presence of one impact the pathology, treatment and outcomes of the other.

The current Rapid Review (RR) forms part of a series of reviews commissioned by the Australian Federal Government to inform the Australian National Eating Disorders Research and Translation Strategy 2021–2031 [ 20 ]. In response to the impact of psychiatric and medical comorbidities on outcomes, this rapid review summarises the recent literature on the nature and implications of psychiatric and medical comorbidities associated with EDs.

The Australian Government Commonwealth Department of Health funded the InsideOut Institute for Eating Disorders (IOI) to develop the Australian Eating Disorders Research and Translation Strategy 2021–2031 [ 20 ] under the Psych Services for Hard to Reach Groups initiative (ID 4-8MSSLE). The strategy was developed in partnership with state and national stakeholders including clinicians, service providers, researchers, and experts by lived experience (both consumers and families/carers). Developed through a two-year national consultation and collaboration process, the strategy provides the roadmap to establishing EDs as a national research priority and is the first disorder-specific strategy to be developed in consultation with the National Mental Health Commission. To inform the strategy, IOI commissioned Healthcare Management Advisors (HMA) to conduct a series of RRs to assess all available peer-reviewed literature on all DSM-5 listed EDs.

A RR Protocol [ 21 ] was utilised to allow swift synthesis of the evidence in order to guide public policy and decision-making [ 22 ]. This approach has been adopted by several leading health organisations including the World Health Organisation [ 17 ] and the Canadian Agency for Drugs and Technologies in Health Rapid Response Service [ 18 ], to build a strong evidence base in a timely and accelerated manner, without compromising quality. A RR is not designed to be as comprehensive as a systematic review—it is purposive rather than exhaustive and provides actionable evidence to guide health policy [ 23 ].

The RR is a narrative synthesis adhering to the PRISMA guidelines [ 24 ]. It is divided by topic area and presented as a series of papers. Three research databases were searched: ScienceDirect, PubMed and Ovid/Medline. To establish a broad understanding of the progress made in the field of EDs, and to capture the largest evidence base from the past 12 years (originally 2009–2019, but expanded to include the preceding two years), the eligibility criteria for included studies were kept broad. Therefore, included studies were published between 2009 and 2021, written in English, and conducted within Western healthcare systems or health systems comparable to Australia in terms of structure and resourcing. The initial search and review process was conducted by three reviewers between 5 December 2019 and 16 January 2020. The re-run for the years 2020–2021 was conducted by two reviewers at the end of May 2021.

The RR had a translational research focus with the objective of identifying evidence relevant to developing optimal care pathways. Searches therefore used a Population, Intervention, Comparison, Outcome (PICO) approach to identify literature relating to population impact, prevention and early intervention, treatment, and long-term outcomes. Purposive sampling focused on high-level evidence studies encompassing meta-analyses; systematic reviews; moderately sized randomised controlled studies (RCTs) (n > 50); moderately sized controlled-cohort studies (n > 50); and population studies (n > 500). However, the diagnoses ARFID and UFED necessitated less stringent eligibility criteria due to a paucity of published articles. As these diagnoses are newly captured in the DSM-5 (released in 2013, within the allocated search timeframe), the evidence base is still emerging, and few studies have been conducted. Thus, smaller studies (n =  ≤ 20) and narrative reviews were also considered and included. Grey literature, such as clinical or practice guidelines, protocol papers (without results) and Masters’ theses or dissertations, were excluded. Other sources (which may not be replicable when applying the current methodology) included the personal libraries of authors, yielding two additional studies (see Additional file 1 ). This extra step was conducted in line with the PRISMA-S: an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Reviews [ 25 ].

Full methodological details including eligibility criteria, search strategy and terms and data analysis are published in a separate protocol paper, which included a total of 1320 studies [ 26 ] (see Additional file 1 : Fig. S1 for PRISMA flow diagram). Data from included studies relating to psychiatric and medical comorbidities of EDs were synthesised and are presented in the current review. No further analyses were conducted.

The search included articles published in the period January 2009 to May 2021. The RR identified 202 studies for inclusion. Of these, 58% related to psychiatric comorbidities (n = 117) and 42% to medical comorbidities (n = 85). A full list of the studies included in this review and information about population, aims and results can be found in Additional file 2 : Tables S3, S4. Results are subdivided into two categories: (1) psychiatric comorbidities and (2) medical complications. Tables 1 and 2 provide high-level summaries of the results.

Psychiatric comorbidities

The study of psychiatric comorbidities can assist with developing models of ED aetiology, conceptualising psychopathology and has relevance for treatment development and outcomes. Given that common psychological factors are observed across psychiatric disorders [ 87 ], it is not surprising that there are high prevalence rates of co-occurring psychiatric conditions with EDs. Comorbidity rates of EDs and other psychiatric conditions are elevated further in ethnic/racial minority groups [ 88 ]. When looking at the evidence from studies conducted with children and young people, one study of children with ARFID found that 53% of the population had a lifetime comorbid psychiatric disorder [ 89 ]. It emerged from the RR that research regarding psychiatric comorbidities generally focussed on the prevalence rates of comorbidities among certain ED subgroups, with some also exploring implications for treatment and ED psychopathology.

Anxiety disorders

Research indicates that EDs and anxiety disorders frequently co-occur [ 8 , 27 ]. The high prevalence rates of anxiety disorders in the general population are also observed in people with EDs; with a large population study finding anxiety disorders were the most frequently comorbid conditions reported [ 8 ]. In a study of women presenting for ED treatment, 65% also met the criteria for at least one comorbid anxiety disorder [ 28 ]. Of note, 69% of those endorsing the comorbidity also reported that the anxiety disorder preceded the onset of the ED [ 28 ]. Another study explored anxiety across individuals with an ED categorised by three weight ranges (individuals whose weight is in the ‘healthy weight’ range, individuals in the ‘overweight’ range and individuals in the ‘obese’ range). While anxiety was elevated across all groups, the authors did note that individuals in the overweight group reported significantly higher rates of anxiety than individuals within the healthy weight group [ 90 ]. One study that explored temperamental factors provided some insight into factors that may mediate this association; anxiety sensitivity (a predictor of anxiety disorders) was associated with greater ED severity among individuals in a residential ED treatment facility [ 29 ]. Further, this association was mediated by a tendency to engage in experiential avoidance—the authors noting that individuals with greater ED symptoms were more likely to avoid distressing experiences [ 29 ].

Generalised anxiety disorder (GAD)

Studies have noted the potential genetic links between EDs and GAD, noting that the presence of one significantly increases the likelihood of the other [ 8 , 30 ]. Further, there appears to be a relationship between the severity of ED behaviours and the co-occurrence of GAD, with comorbidity more likely when fasting and excessive exercise are present, as well as a lower BMI [ 30 ]. The authors noted the particularly pernicious comorbidity of EDs (specifically AN) and GAD may be amplified by the jointly anxiolytic and weight loss effects of food restriction and excessive exercise [ 30 ].

Social anxiety

A meta-analysis of 12 studies found higher rates of social anxiety across all ED diagnoses, with patients with BN demonstrating the highest rate of comorbidity at 84.5%, followed by both BED and AN-BP both at 75% [ 31 ]. High levels of social anxiety were also associated with more severe ED psychopathology [ 31 ] and higher body weight [ 91 ]. This particular comorbidity may also impact on access to treatment for the ED; a large follow-up study of adolescents found that self-reported social phobia predicted not seeking treatment for BN symptoms [ 32 ]. Interestingly, two studies noted that anxiety symptoms improved following psychological treatments that targeted ED symptoms, possibly due to a shared symptom profile [ 29 , 31 ].

Obsessive–compulsive disorder

Similarities between the symptoms of Obsessive–Compulsive Disorder (OCD) and EDs, such as cognitive rigidity, obsessiveness, detail focus, perfectionism and compulsive routines have long been reported in the literature [ 34 ]. Given the symptom overlap, a meta-analysis sought to clarify the lifetime and current (that is, a current diagnosis at the time of data collection) comorbidity rates of OCD and EDs, noting the lifetime comorbidity rate was 18% and current comorbidity rate was 15% [ 33 ]. However, the authors noted that this prevalence may double over longer periods of observation, with some follow-up data demonstrating comorbidity rates of 33% [ 33 ]. Prevalence rates of OCD seemed to be highest among people with AN (lifetime = 19% and current = 14%) compared to other ED subtypes. In addition to the symptom crossover, this RR found evidence of a complex relationship between OCD and EDs, including a potential association between OCD and greater ED severity [ 34 ].

Network analysis found that doubts about simple everyday things and repeating things over and over bridged between ED and OCD symptoms. Further, a pathway was observed between restricting and checking compulsions and food rigidity as well as binge eating and hoarding. However, as the data was cross-sectional, directional inferences could not be made [ 36 ]. An earlier study explored how changes in OCD symptoms impact ED symptoms among an inpatient sample [ 35 ]. As was hypothesised, decreases in OCD symptoms accounted for significant variance in decreases in ED symptoms, and this effect was strongest among ED patients with comorbid OCD. The study also found that irrespective of whether patients had comorbid OCD or not, when ED symptoms improved, so did symptoms of OCD [ 35 ]. The authors concluded that perhaps there is a reciprocal relationship between OCD and ED symptoms, whereby symptoms of both conditions interact in a synergistic, bidirectional manner, meaning that improvement in one domain can lead to improvement in another [ 35 ]. These findings were somewhat supported in a study by Simpson and colleagues (2013), which found exposure and response prevention (a specialised OCD treatment) resulted in a significant reduction in OCD severity, as was expected, and an improvement in ED symptoms. In their study, individuals with BN showed more improvement than those with AN–nevertheless, BMI still increased among those underweight [ 92 ].

Mood disorders

Depression and major depressive disorder (mdd).

This RR also found high levels of comorbidity between major depression and EDs. A longitudinal study of disordered eating behaviours among adolescents found that disordered eating behaviours and depressive symptoms developed concurrently [ 37 ]. Among the sample, over half the adolescent sample had a depressive disorder. Prevalence rates were similar for AN (51.5%) and BN (54%) [ 37 ]. The study also explored the neurological predictors of comorbid depression in individuals with EDs, noting that lower grey matter volumes in the medial orbitofrontal, dorsomedial, and dorsolateral prefrontal cortices predicted the concurrent development of purging and depressive symptoms [ 37 ]. The results suggested that alterations in frontal brain circuits were part of a neural aetiology common to EDs and depression [ 37 ].

This RR found much support for a strong relationship between depression and ED symptomatology. In a study of patients with AN, comorbid MDD was associated with a greater AN symptom severity [ 93 ], and this relationship between the symptoms of MDD and AN was bidirectional in a study of adolescents undergoing treatment for AN, whereby dietary restraint predicted increased guilt and hostility (symptoms of low mood) and fear predicted further food restriction [ 94 ]. Further studies noted the association between BN, BED and NES, with a higher prevalence of depression and more significant depression symptoms [ 95 , 96 , 97 ]. However, other studies have failed to find support for this association–for example, a Swedish twin study found no association between NES and other mental health disorders [ 98 ].

The impact of the relationship between depression and EDs on treatment outcomes was variable across the studies identified by the RR. One study noted the impact of depression on attrition; patients with BN and comorbid depression attending a university clinic had the highest rates of treatment drop-out [ 99 ]. However, in a sample of patients with AN, the comorbidity of depression (or lack of) did not impact treatment outcome and the severity of depression was not associated with changes in ED symptoms [ 100 ]. This finding was supported in another study of inpatients with AN; pre-treatment depression level did not predict treatment outcome or BMI [ 101 ].

Bipolar disorders

Notable comorbidity rates between bipolar disorders (BD) and EDs were reported in the literature reviewed, however evidence about the frequency of this association was mixed. Studies noted comorbidity rates of BD and EDs ranging between 1.9% to as high as 35.8% [ 38 , 39 , 40 ]. In order to better understand the nature of comorbidity, a recent systematic review and meta-analysis found BD (including bipolar 1 disorder and bipolar 2 disorder) and ED comorbidity varied across different ED diagnostic groups (BED—12.5%, BN—7.4%, AN—3.8%) [ 102 ]. However, the authors noted the scant longitudinal studies available, particularly in paediatric samples. An analysis of comorbidity within a sample of patients with BD identified that 27% of participants also met criteria for an ED; 15% had BN, 12% had BED, and 0.2% had AN [ 103 ]. Two other studies noted considerable comorbidity rates of BD; 18.6% for binge eating [ 104 ] and 8.8% for NES [ 105 ]. Some studies suggested the co-occurrence of BD and EDs were seen most in people with AN-BP, BN and BED—all of which share a binge and/or purge symptom profile [ 38 , 106 ]. Specifically, BED and BN were the most common co-occurring EDs with BD [ 40 ], however, these EDs are also the most prevalent in the population. Therefore, it is unclear if this finding is reflective of the increased prevalence of BN and BED, or if it reflects a shared underlying psychopathology between BD and these EDs [ 40 ].

Comorbid ED-BD patients appear to experience increased ED symptom severity, poorer daily and neuropsychological functioning than patients with only a ED or BD diagnosis [ 107 ]. In an effort to understand which shared features in ED-BD relate to quality of life, one study assessed an adult sample with BD [ 108 ]. Binge eating, restriction, overevaluation of weight and shape, purging and driven exercise were associated with poorer clinical outcomes, quality of life and mood regulation [ 108 ]. Additionally, a study of patients undergoing treatment for BD noted patients with a comorbid ED had significantly poorer clinical outcomes and higher scores of depression [ 109 ]. Further, quality of life was significantly lower among patients with comorbid ED-BD [ 109 ]. The comorbidity of ED and BD has implications for intervention and clinical management, as at least one study observed higher rates of alcohol abuse and suicidality among patients with comorbid ED and BD compared to those with BD only [ 40 ].

Personality disorders

This RR identified limited research regarding the comorbidity between personality disorders (PD) and EDs. A meta-analysis sought to summarise the proportion of comorbid PDs among patients with AN and BN [ 41 ]. There was a heightened association between any type of ED and PDs, and this was significantly different to the general population. For specific PDs, the proportions of paranoid, borderline, avoidant, dependant and obsessive–compulsive PD were significantly higher in EDs than in the general population. For both AN and BN, Cluster C PDs (avoidant, dependant and obsessive–compulsive) were most frequent. The authors noted that the specific comorbidity between specific EDs and PDs appears to be associated with common traits—constriction/perfectionism and rigidity is present in both AN and obsessive–compulsive PD (which had a heightened association), as was the case with impulsivity, a characteristic of both BN and borderline PD [ 41 ]. This symptom association was also observed in a study of adolescents admitted to an ED inpatient unit whereby a significant interaction between binge-purge EDs (AN-BP and BN), childhood emotional abuse (a risk factor for PD) and borderline personality style was found [ 110 ].

This comorbidity may be associated with greater patient distress and have implications for patient outcomes [ 41 , 42 ]. Data from a nine-year observational study of individuals with BN reported that comorbidity with a PD was strongly associated with elevated mortality risk [ 111 ]. In terms of treatment outcomes, an RCT compared the one- and three-year treatment outcomes of four subgroups of women with BN, defined by PD complexity; no comorbid PD (health control), personality difficulties, simple PD and complex PD [ 112 ]. At pre-treatment, the complex PD group had greater ED psychopathology than the other three groups. Despite this initial difference, there were no differences in outcomes between groups at one-year and three-year follow up [ 112 ]. The authors suggested this result could be due to the targeting of the shared symptoms of BN and PD by the intervention delivered in this study, and that as ED symptoms improve, so do PD symptoms [ 112 ]. Suggesting that beyond symptom overlap, perhaps some symptoms attributed to the PD are better explained by the ED. This was consistent with Brietzke and colleagues’ (2011) recommendation that for individuals with ED and a comorbid PD, treatment approaches should target both conditions where possible [ 113 ].

Substance use disorders

Comorbid substance use disorders (SUDs) are also often noted in the literature as an issue that complicates treatment and outcomes of EDs [ 114 ]. A meta-analysis reported the lifetime prevalence of EDs and comorbid SUD was 27.9%, [ 43 ] with a lifetime prevalence of comorbid illicit drug use of 17.2% for AN and 18.6% for BN [ 115 ]. Alcohol, caffeine and tobacco were the most frequently reported comorbidities [ 43 ]. Further analysis of SUDs by substance type in a population-based twin sample indicated that the lifetime prevalence of an alcohol use disorder among individuals with AN was 22.4% [ 115 ]. For BN, the prevalence rate was slightly higher at 24.0% [ 115 ].

The comorbidity of SUD is considered far more common among individuals with binge/purge type EDs, evidenced by a meta-analysis finding higher rates of comorbid SUD among patients with AN-BP and BN than AN-R [ 44 ]. This trend was also observed in population data [ 116 ]. Further, a multi-site study found that patients with BN had higher rates of comorbid SUD than patients with AN, BED and Eating Disorder Not Otherwise Specific (EDNOS) (utilised DSM-IV criteria) [ 117 ]. Behaviourally, there was an association between higher frequencies of binge/purge behaviours with high rates of substance use [ 117 ]. The higher risk of substance abuse among patients with binge/purge symptomology was also associated with younger age of binge eating onset [ 118 ]. A study explored whether BN and ED subtypes with binge/purge symptoms predicted adverse outcomes and found that adolescent girls with purging disorder were significantly more likely to use drugs or frequently binge drink [ 119 ]. This association was again observed in a network analysis of college students, whereby there was an association between binge drinking and increased ED cognitions [ 120 ].

Psychosis and schizophrenia

The RR identified a small body of literature with mixed results regarding the comorbidity of ED and psychosis-spectrum symptoms. A study of patients with schizophrenia found that 12% of participants met full diagnostic criteria for NES, with a further 10% meeting partial criteria [ 45 ]. Miotto and colleagues’ (2010) study noted higher rates of paranoid ideation and psychotic symptoms in ED patients than those observed in healthy controls [ 121 ]. However, the authors concluded that these symptoms were better explained by the participant's ED diagnosis than a psychotic disorder [ 121 ]. At a large population level, an English national survey noted associations between psychotic-like experiences and uncontrolled eating, food dominance and potential EDs [ 122 ]. In particular, these associations were stronger in males [ 122 ]. However, the true comorbidity between psychotic disorders and ED remains unclear and further research is needed.

Body dysmorphic disorder

While body image disturbances common to AN, BN and BED are primarily related to weight and shape concerns, individuals with body dysmorphic disorder (BDD) have additional concerns regarding other aspects of their appearance, such as facial features and skin blemishes [ 46 , 123 ]. AN and BDD share similar psychopathology and both have a peak onset period in adolescence, although BDD development typically precedes AN [ 46 ]. The prevalence rates of BDD among individuals with AN are variable. In one clinical sample of female AN patients, 26% met BDD diagnostic criteria [ 124 ]. However, much higher rates were observed in another clinical sample of adults with AN, where 62% of patients reported clinically significant 'dysmorphic concern' [ 125 ].

As the RR has found with other mental health comorbidities, BDD contributes to greater symptom severity in individuals with AN, making the disorder more difficult to treat. However, some research suggested that improved long-term outcomes from treatments for AN are associated with the integration of strategies that address dysmorphic concerns [ 124 , 126 ]. However, there remains little research on the similarities, differences and co-occurrence of BDD and AN, and with even less research on the cooccurrence of BDD and other EDs.

Neurodevelopmental disorders

Attention deficit hyperactivity disorder

Several studies noted the comorbidity between Attention Deficit Hyperactivity Disorder (ADHD) and EDs. A systematic review found moderate evidence for a positive association between ADHD and disordered eating, particularly between overeating and ADHD [ 47 ]. The impulsivity symptoms of ADHD were particularly associated with BN for all genders, and weaker evidence was found for the association between hyperactivity and restrictive EDs (AN and ARFID) for males, but not females [ 47 ]. Another meta-analysis reported a two-fold increased risk of ADHD in individuals with an ED [ 48 ] and studies have noted particularly strong associations between ADHD and BN [ 49 , 50 ]. In a cohort of adults with a diagnosis of an ED, 31.3% had a 'possible' ADHD [ 127 ]. Another study considered sex differences; women with ADHD had a significantly higher lifetime prevalence of both AN and BN than women without ADHD [ 128 ]. Further, the comorbidity rates for BED were considerably higher among individuals with ADHD for both genders [ 128 ].

Further evidence for a significant association between ADHD and EDs was reported in a population study of children [ 51 ]. Results revealed that children with ADHD were more like to experience an ED or binge, purge, or restrictive behaviours above clinical threshold [ 51 ]. Another study of children with ADHD considered gender differences; boys with ADHD had a greater risk of binge eating than girls [ 129 ]. However, the study found no significant difference in AN's prevalence between ADHD and non-ADHD groups. Further, among patients attending an ED specialist clinic, those with comorbid ADHD symptoms had poorer outcomes at one-year follow-up [ 130 ].

Autism spectrum disorder

There is evidence of heightened prevalence rates of autism spectrum disorder (ASD) among individuals with EDs. A systematic review found an average prevalence of ASD with EDs of 22.9% compared with 2% observed in the general population [ 52 ]. With regards to AN, several studies have found symptoms of ASD to be frequently exhibited by patients with AN [ 53 , 54 ]. An assessment of common phenomena between ARFID and ASD in children found a shared symptom profile of eating difficulties, behavioural problems and sensory hypersensitivity beyond what is observed in typically developing children (the control group) [ 55 ]. While research in this area is developing, the findings indicated these comorbidities would likely have implications for the treatment and management of both conditions [ 55 ].

Post traumatic stress disorder

Many individuals with EDs report historical traumatic experiences, and for a proportion of the population, symptoms of post traumatic stress disorder (PTSD). A broad range of prevalence rates between PTSD and EDs have been reported; between 16.1–22.7% for AN, 32.4–66.2% for BN and 24.02–31.6% for BED [ 56 ]. A review noted self-criticism, low self-worth, guilt, shame, depression, anxiety, emotion dysregulation, anger and impulsivity were linked to the association between EDs and trauma [ 57 ]. It was suggested that for individuals with trauma/PTSD, EDs might have a functional role to manage PTSD symptoms and reduce negative affect [ 57 ]. Further, some ED behaviours such as restriction, binge eating, and purging may be used to avoid hyperarousal, in turn maintaining the association between EDs and PTSD [ 57 ].

Few studies have explored the impact of comorbid PTSD on ED treatment outcomes. A study of inpatients admitted to a residential ED treatment service investigated whether PTSD diagnosis at admission was associated with symptom changes [ 56 ]. Cognitive and behavioural symptoms related to the ED had decreased at discharge, however, they increased again at six-month follow up. In contrast, while PTSD diagnosis was associated with higher baseline ED symptoms, it was not related to symptom change throughout treatment or treatment dropout [ 56 ]. Given previous research identified that PTSD and EDs tend to relate to more complex courses of illness, greater rates of drop out and poorer outcomes, a study by Brewerton and colleagues [ 131 ], explored the presence of EDs in patients with PTSD admitted to a residential setting. Results showed that patients with PTSD had significantly higher scores of ED psychopathology, as well as depression, anxiety and quality of life. [ 131 ]. Further, those with PTSD had a greater tendency for binge-type EDs.


Suicide is one of the leading causes of death for individuals with EDs [ 58 ]. In a longitudinal study of adolescents, almost one quarter had attempted suicide, and 65% reported suicidal ideation within the past 6 months [ 37 ]. EDs are a significant risk factor for suicide, with some evidence suggesting a genetic association between suicide risk and EDs [ 59 , 60 ]. This association was supported in the analysis of Swedish population registry data, which found that individuals with a sibling with an ED had an increased risk of suicide attempts with an odds ratio of 1.4 (relative cohort n  = 1,680,658) [ 61 ]. For suicide attempts, this study found an even higher odds ratio of 5.28 (relative cohort n  = 2,268,786) for individuals with an ED and 5.39 (relative cohort n  = 1,919,114) for death by suicide [ 61 ]. A comparison of individuals with AN and BN indicated that risk for suicide attempts was higher for those with BN compared to AN [ 61 ]. However, the opposite was true for death by suicide; which was higher in AN compared to BN [ 61 ]. This result is consistent with the findings of a meta-analysis—the incidence of suicide was higher among patients with AN compared to those with BN or BED [ 62 ].

The higher incidence of suicide in adults with AN [ 132 ] is potentially explained by the findings from Guillaume and colleagues (2011), which suggested that comparative to BN, AN patients are more likely to have more serious suicide attempts resulting in a higher risk of death [ 133 ]. However, death by suicide remains a significant risk for both diagnoses. As an example, Udo and colleagues (2019) study reported that suicide attempts were more common in those with an AN-BP subtype (44.1%) than AN-R (15.7%), or BN (31.4%) [ 134 ]. Further, in a large cohort of transgender college students with EDs, rates of past-year suicidal ideation (a significant risk factor for suicide attempts) was 75.2%, and suicide attempts were 74.8%, significantly higher than cisgender students with EDs and transgender students without EDs [ 135 ]. The RR found that the risk of suicidal ideation and behaviour was associated with ED diagnosis and the presence of other comorbidities. Among a community-based sample of female college students diagnosed with an ED, 25.6% reported suicidal ideation, and this was positively correlated with depression, anxiety and purging [ 136 ]. In support of this evidence, Sagiv and Gvion (2020) proposed a dual pathway model of risk of suicide attempt in individuals with ED, which implicates trait impulsivity and comorbid depression [ 137 ]. In two large transdiagnostic ED patient samples, suicidal ideation was associated with different aspects of self-image between ED diagnoses. For example, suicidal ideation was associated with higher levels of self-blame among individuals with BED, while among patients with AN and OSFED, increased suicidal ideation was associated with a lack of self-love [ 138 , 139 ].

Anorexia nervosa

Amongst adults with AN, higher rates of suicide have been reported amongst those with a binge-purge subtype (25%) than restrictive subtype (8.65%) [ 58 , 140 ]. Further, comorbid depression and prolonged starvation were strongly associated with elevated suicide attempts for both subtypes [ 58 , 140 ]. In another study, the risk of attempted suicide was associated with depression, but it was moderated by hospital treatment [ 93 ]. Further, suicidal ideation was related to depression. A significant 'acquired' suicide risk in individuals with AN has been identified by Selby et al. (2010) through an increased tolerance for pain and discomfort resultant from repeated exposure to painful restricting and purging behaviours [ 141 ].

Bulimia nervosa

Further research among individuals diagnosed with BN found an increased level of suicide risk [ 142 ]. Results from an extensive study of women with BN indicated that the lifetime prevalence of suicide attempts in this cohort was 26.9% [ 143 ]. In one study of individuals diagnosed with severe BN, 60% of deaths were attributed to suicide [ 144 ]. The mean age at the time of death was 29.6 years, and predictive factors included previous suicide attempts and low BMI. Further, in a sample of children and adolescents aged 7 to 18 years, higher rates of suicidal ideation were associated with BN, self-induced vomiting and a history of trauma [ 12 ].

A large population-based study of adolescents and adults explored the frequency and correlates of suicidal ideation and attempts in those who met the criteria for BN [ 145 ]. Suicidal ideation was highest in adolescents with BN (53%), followed by BED (34.4%), other non-ED psychopathology (21.3%) or no psychopathology (3.8%). A similar trend was observed for suicide plans and attempts [ 145 ]. However, for adults, suicidality was more prevalent in the BN group compared to no psychopathology, but not statistically different to the AN, BED or other psychopathology groups [ 145 ].

Consistent with Crow and colleagues’ (2014) results, in a sample of women with BN, depression had the strongest association with lifetime suicide attempts [ 146 ]. There were also associations between identity problems, cognitive dysregulation, anxiousness, insecure attachment and lifetime suicide attempts among the sample. Depression was the most pertinent association, suggesting that potential comorbid depression should be a focus of assessment and treatment among individuals with BN due to the elevated suicide risk for this group [ 146 ]. Insecure attachment is associated with childhood trauma, and a systematic review found that suicide attempts in women with BN were significantly associated with childhood abuse and familial history of EDs [ 58 ].

Binge eating disorder

The RR found mixed evidence for the association between suicidal behaviour and BED. A meta-analysis found no suicides for patients with BED [ 62 ]. However, evidence from two separate large national surveys found that a significant proportion of individuals who had a suicide attempt also had a diagnosis of BED [ 134 , 147 ].

Non-suicidal self injury

Non-suicidal self-injury (NSSI), broadly defined, is the intentional harm inflicted to one’s body without intent to die [ 148 ]. Recognising NSSI is often a precursor for suicidal ideation and behaviour [ 149 ], together with the already heightened mortality rate for EDs, several studies have examined the association between EDs and NSSI. Up to one-third of patients with EDs report NSSI at some stage in their lifetime, with over one quarter having engaged in NSSI within the previous year [ 63 ]. Similarly, a cohort study [ 148 ] found elevated rates of historical NSSI amongst patients with DSM-IV EDs; specifically EDNOS (49%), BN (41%) and AN (26%). In a Spanish sample of ED patients, the most prevalent form of NSSI was banging (64.6%) and cutting (56.9%) [ 63 ].

Further research has explored the individual factors associated with heightened rates of NSSI. Higher levels of impulsivity among patients with EDs have been associated with concomitant NSSI [ 64 ]. This was demonstrated in a longitudinal study of female students, whereby NSSI preceded purging, marking it a potential risk factor for ED onset [ 65 ]. In a study of a large clinical sample of patients with EDs and co-occurring NSSI, significantly higher levels of emotional reactivity were observed [ 150 ]. The highest levels of emotional reactivity were reported by individuals with a diagnosis of BN, who were also more likely to engage in NSSI than those with AN [ 150 ]. In Olatunji and colleagues’ (2015) cohort study, NSSI was used to regulate difficult emotions, much like other ED behaviours. NSSI functioning as a means to manage negative affect associated with EDs was further supported by Muehlenkamp and colleagues’ [ 66 ] study exploring the risk factors in inpatients admitted for an ED. The authors found significant differences in the prevalence of NSSI across ED diagnoses, although patients with binge/purge subtype EDs were more likely to engage in poly-NSSI (multiple types of NSSI). Consistent with these findings, a study of patients admitted to an ED inpatient unit found that 45% of patients displayed at least one type of NSSI [ 151 ]. The function of NSSI among ED patients was explored in two studies, one noting that avoiding or suppressing negative feelings was the most frequently reported reason for NSSI [ 151 ]. The other analysed a series of interviews and self-report questionnaires and found patients with ED and comorbid Borderline Personality Disorder (BPD) engaged in NSSI as a means of emotion regulation [ 152 ].

Medical comorbidities

The impact of EDs on physical health and the consequential medical comorbidities has been a focus of research. Many studies reported medical comorbidities resulting from prolonged malnutrition, as well as excessive exercise, binging and purging behaviours.

Cardiovascular complications

As discussed above, although suicide is a significant contributor to the mortality rate of EDs, physical and medical complications remain the primary cause of death, particularly in AN, with a high proportion of deaths thought to result from cardiovascular complications [ 153 ]. AN has attracted the most research focus given its increased risk of cardiac failure due to severe malnutrition, dehydration and electrolyte imbalances [ 67 ].

Cardiovascular complications in AN can be divided by conduction, structural and ischemic diseases. A review found that up to 87% of patients experience cardiovascular compromise shortly following onset of AN [ 153 ]. Within conduction disease, bradycardia and QT prolongation occur at a high frequency, largely due to low body weight and resultant decreased venous return to the heart. Whereas, atrioventricular block and ventricular arrhythmia are more rare [ 153 ]. Various structural cardiomyopathies are observed in AN, such as low left ventricular mass index (occurs frequently), mitral prolapse and percardial effusion (occurs moderately). Ischemic diseases such as dyslipidemia or acute myocardial infarction are more rare.

Another review identified cardiopulmonary abnormalities that are frequently observed in AN; mitral valve prolapse occurred in 25% of patients, sinus bradycardia was the most common arrhythmia, and pericardial effusion prevalence rates ranged from 15 to 30%. [ 68 ] Sudden cardiac death is thought to occur due to increased QT interval dispersion and heart rate variability. [ 68 ] A review of an inpatient database in a large retrospective cohort study found that coronary artery disease (CAD) was lower in AN patients than the general population (4.4% and 18.4%, respectively). Consistent with trends in the general population, the risk of cardiac arrest, arrhythmias and heart failure was higher in males with AN than females with AN [ 69 ].

Given that individuals with AN have compromised biology, may avoid medical care, and have higher rates of substance use, research has examined cancer incidence and prognosis among individuals with AN. A retrospective study noted higher mortality from melanoma, cancers of genital organs and cancers of unspecified sites among individuals with AN, however, there was no statistically significant difference compared to the general population [ 70 ]. No further studies of cancer in EDs were identified.

Gastrointestinal disorders

The gastrointestinal (GI) system plays a pivotal role in the development, maintenance, and treatment outcomes for EDs, with changes and implications present throughout the GI tract. More than 90% of AN patients report fullness, early satiety, abdominal distention, pain and nausea [ 68 ]. Although it is well understood that GI system complaints are complicated and exacerbated by malnutrition, purging and binge eating [ 154 , 155 ], the actual cause of the increased prevalence of GI disorders and their contribution to ED maintenance remain poorly understood.

To this end, a review aimed to determine the GI symptoms reported in two restrictive disorders (AN and ARFID), as well as the physiologic changes as a result of malnutrition and function of low body weight and the contribution of GI diseases to the disordered eating observed in AN and ARFID [ 156 ]. The review found mixed evidence regarding whether GI issues were increased in patients with AN and ARFID. This was partly due to the relatively limited amount of research in this area and mixed results across the literature. The review noted that patients with AN and ARFID reported a higher frequency of symptoms of gastroparesis. Further, there was evidence for a bidirectional relationship between AN and functional gastrointestinal disorders (FGIDs) contributing to ongoing disordered eating. The review found that GI symptoms observed in EDs develop due to (1) poorly treated medical conditions with GI-predominant symptoms, (2) the physiological and anatomical changes that develop due to malnutrition or (3) FGIDs.

There was a high rate of comorbidity (93%) between ED and FGIDs, including oesophageal, bowel and anorectal disorders, in a patient sample with AN, BN and EDNOS [ 157 ]. A retrospective study investigating increased rates of oesophageal cancer in individuals with a history of EDs could not conclude that risk was associated with purging over other confounding factors such as alcohol abuse and smoking [ 158 ].

Given that gut peptides like ghrelin, cholecystokinin (CCK), peptide tyrosine (PYY) and glucagon-like peptide 1 (GLP-1) are known to influence food intake, attention has focussed on the dysregulation of gut peptide signalling in EDs [ 159 ]. A review aimed to discuss how these peptides or the signals triggered by their release are dysregulated in EDs and whether they are normalised following weight restoration or weight loss (in the case of people with higher body weight) [ 159 ]. The results were inconsistent, with significant variability in peptide dysregulation observed across EDs [ 159 ]. A systematic review and meta-analysis explored whether ghrelin is increased in restrictive AN. The review found that all forms of ghrelin were raised in AN’s acute state during fasting [ 160 ]. In addition, the data did not support differences in ghrelin levels between AN subtypes [ 160 ]. Another study examined levels of orexigenic ghrelin and anorexigenic peptide YY (PYY) in young females with ARFID, AN and healthy controls (HC) [ 161 ]. Results demonstrated that fasting and postprandial ghrelin were lower in ARFID than AN, but there was no difference between ARFID and AN for fasting and postprandial PYY [ 161 ].

Oesophageal and gastrointestinal dysfunction have been observed in patients with AN and complicate nutritional and refeeding interventions [ 155 ]. Findings from a systematic review indicated that structural changes that occurred in the GI tract of patients with AN impacted their ability to swallow and absorb nutrients [ 162 ]. Interestingly, no differences in the severity of gastrointestinal symptoms were observed between AN-R and AN-BP subtypes [ 155 ].

A systematic review of thirteen studies aimed to identify the most effective treatment approaches for GI disorders and AN [ 163 ]. An improvement in at least one or more GI symptoms was reported in 11 of the 13 studies, with all studies including nutritional rehabilitation, and half also included concurrent psychological treatment [ 163 ]. Emerging evidence on ED comorbidity with chronic GI disorders suggested that EDs are often misdiagnosed in children and adolescents due to the crossover of symptoms. Therefore, clinicians treating children and adolescents for GI dysfunction should be aware of potential EDs and conduct appropriate screening [ 164 ]. There has been an emerging focus on the role of the gut microbiome in the regulation of core ED symptoms and psychophysiology. Increased attention is being paid to how the macronutrient composition of nutritional rehabilitation should be considered to maximise treatment outcomes. A review found that high fibre consumption in addition to prebiotic and probiotic supplementation helped balance the gut microbiome and maintained the results of refeeding [ 165 ].

Bone health

The RR found evidence for bone loss/poor bone mineral density (BMD) and EDs, particularly in AN. The high rates of bone resorption observed in patients with AN is a consequence of chronic malnutrition leading to osteoporosis (weak and brittle bones), increased fracture risk and scoliosis [ 166 ]. The negative impacts of bone loss are more pronounced in individuals with early-onset AN when the skeleton is still developing [ 67 ] and among those who have very low BMI [ 71 ], with comorbidity rates as high as 46.9% [ 71 ]. However, lowered BMD was also observed among patients with BN [ 72 ].

A review [ 167 ] explored the prevalence and differences in pathophysiology of osteoporosis and fractures in patients with AN-R and AN-BP. AN-R patients had a higher prevalence of osteoporosis, and AN-BP patients had a higher prevalence of osteopenia (loss of BMD) [ 167 ]. Further, the authors noted the significant increase in fracture risk that starts at disease onset and lasts throughout AN, with some evidence that risk remains increased beyond remission and recovery [ 167 ]. Findings from a longitudinal study of female patients with a history of adolescent AN found long-term bone thinning at five and ten-year follow-up despite these patients achieving weight restoration [ 168 ].

Given this, treatment to increase BMD in individuals with AN has been the objective of many pharmacotherapy trials, mainly investigating the efficacy of hormone replacement [ 169 , 170 ]. Treatments include oestrogen and oral contraceptives [ 169 , 170 , 171 , 172 ]; bisphosphonates [ 169 , 173 ]; other hormonal treatment [ 174 , 175 , 176 , 177 ] and vitamin D [ 178 ]. However, the outcomes of these studies were mixed.

Refeeding syndrome

Nutritional rehabilitation of severely malnourished individuals is central to routine care and medical stabilisation of patients with EDs [ 179 ]. Within inpatient treatment settings, reversing severe malnutrition is achieved using oral, or nasogastric tube feeding. However, following a period of starvation, initiating/commencing feeding has been associated with ‘refeeding syndrome’ (RFS), a potentially fatal electrolyte imbalance caused by the body's response to introducing nutritional restoration [ 180 , 181 ]. The studies identified in the RR focused predominantly on restrictive EDs/on this population group—results regarding RFS risk were mixed [ 73 ].

A retrospective cohort study of inpatients diagnosed with AN with a very low BMI implemented a nasogastric feeding routine with vitamin, potassium and phosphate supplementation [ 182 ]. All patients achieved a significant increase in body weight. None developed RFS [ 182 ], suggesting that even with extreme undernutrition, cautious feeding within a specialised unit can be done safely without RFS. For adults with AN, aminotransferases are often high upon admission, however are normalised following four weeks of enteral feeding [ 183 , 184 ]. Further, the RR identified several studies demonstrating the provision of a higher caloric diet at intake to adolescents with AN led to faster recoveries and fewer days in the hospital with no observed increased risk for RFS [ 75 , 76 , 77 ]. These findings were also noted in a study of adults with AN [ 179 ].

However, the prevalence of RFS among inpatients is highly variable, with one systematic review noting rates ranging from 0 to 62% [ 74 ]. This variability was largely a reflection of the different definitions of RFS used across the literature [ 74 ]. A retrospective review of medical records of patients with AN admitted to Intensive Care Units (ICUs) aimed to evaluate complications, particularly RFS, that occurred during the ICU stay and the impact of these complications on treatment outcomes [ 185 ]. Of the 68 patients (62 female), seven developed RFS (10.3%) [ 185 ].

Although easily detectable and treatable, hypophosphatemia (a low serum phosphate concentration) may lead to RFS which is the term used to describe severe fluid and electrolyte shifts that can occur when nutrition support is introduced after a period of starvation. Untreated hypophosphatemia may lead to characteristic signs of the RFS such as respiratory failure, heart failure, and seizures [ 76 , 179 , 186 , 187 , 188 ]. A retrospective case–control study of inpatients with severe AN identified [ 189 ]. A retrospective study of AN and atypical AN patients undergoing refeeding found that the risk of hypophosphatemia was associated with a higher level of total weight loss and recent weight loss rather than the patient’s weight at admission [ 190 ]. The safe and effective use of prophylactic phosphate supplementation during refeeding was supported by the results from Agostino and colleagues’ chart review study [ 191 ], where 90% of inpatients received supplementation during admission.

Higher calorie refeeding approaches are considered safe in most cases, however the steps necessitated to monitor health status are costly to health services [ 192 ]. The most cost-effective approach would likely involve prophylactic electrolyte supplementation in addition to high calorie refeeding, which would decrease the need for daily laboratory monitoring as well as shortening hospital stays [ 75 , 191 , 192 ]. A systematic review noted that much of the research regarding refeeding, particularly in children and young people, has been limited by small sample sizes, single-site studies and heterogeneous designs [ 181 ]. Further, the differing definitions of RFS, recovery, remission and outcomes leading to variable results. While RFS appears safe for many people requiring feeding, the risk and benefits of it are unclear [ 193 ] due to the limited research on this topic. Following current clinical practice guidelines on the safe introduction of nutrition is recommended.

Metabolic syndrome

Metabolic syndrome refers to a group of factors that increase risks for heart disease, diabetes, stroke and other related conditions [ 194 ]. Metabolic syndrome is conceptualised as five key criteria; (1) elevated waist circumference, (2) elevated triglyceride levels, (3) reduced HDL-C, (4) elevated blood pressure and (5) elevated fasting glucose. The binge eating behaviours exhibited in BN, BED and NES have been linked to the higher rates of metabolic syndrome observed in these ED patients [ 78 , 195 ].

An analysis of population data of medical comorbidities with BED noted the strongest associations were with diabetes and circulatory systems, likely indexing components of metabolic syndrome [ 196 ]. While type 1 diabetes is considered a risk factor for ED development, both BN and BED have increased risk for type 2 diabetes [ 78 ]. A 16-year observation study found that the risk of type 2 diabetes was significantly increased in male patients with BED compared to the community controls [ 78 ]. By the end of the observation period, 33% of patients with BED had developed type 2 diabetes compared to 1.7% of the control group. The prevalence of type 2 diabetes among patients with BN was also slightly elevated at 4.4% [ 78 ]. Importantly, the authors were not able to control for BMI in this study. In another study, BED was the most prevalent ED in a cohort of type 2 diabetes patients [ 197 ]. Conversely, the prevalence of AN among patients with type 2 diabetes is significantly lower, with a review of national data reporting comorbidity rates to be 0.06% [ 198 ].

Metabolic dysfunction was observed in a relatively large sample of individuals with NES, including metabolic syndrome and type 2 diabetes, with women reporting slightly higher rates (13%) than men (11%) [ 199 ]. In another group of adults with type 2 diabetes, 7% met the diagnostic criteria for NES [ 200 ]. These findings suggested a need for increased monitoring and treatment of type 2 diabetes in individuals with EDs, particularly BED and NES. Another study found BED had a significant impact on metabolic abnormalities, including elevated cholesterol and poor glycaemic control [ 201 ].

The RR identified one intervention study, which examined an intervention to address medical comorbidities associated with BN and BED [ 195 ]. The study compared cognitive behaviour therapy (CBT) to an exercise and nutrition intervention to increase physical fitness, decrease body fat percentage and reduce the risk for metabolic syndrome. While the exercise intervention improved participants' physical fitness and body composition, neither group reduced cardiovascular risk at one-year follow-up [ 195 ].

Oral health

Purging behaviour, particularly self-induced vomiting, has been associated with several oral health and gastrointestinal dysfunctions in patients with EDs. A case–control study of ED patients with binge/purge symptomology found that despite ED patients reporting an increased concern for dental issues and engaging in more frequent brushing, their oral health was poorer than controls. [ 79 ] Further, a systematic review and meta-analysis aimed to explore whether EDs increase the risk of tooth erosion [ 80 ]. The analysis found that patients with EDs had more risk of dental erosion, especially among those who self-induced vomiting [ 80 ]. These findings were also found in a large cohort study, where the increased risk for BN was associated with higher rates of dental erosion but not dental cavities [ 81 ].

However, a systematic review of 10 studies suggested that poor oral health may be common among ED patients irrespective of whether self-induced vomiting forms part of their psychopathology [ 202 ]. One study reported that AN-R patients had poorer oral health outcomes and tooth decay than BN patients [ 203 ]. Two studies identified associations between NES and poor oral health, including higher rates of missing teeth, periodontal disease [ 204 , 205 ]. Another study of a group of patients with AN, BN and EDNOS, demonstrated the impact of ED behaviours on dental soft tissue, whereby 94% of patients had oral mucosal lesions, and 3% were found to have dental erosion [ 206 ].

Vitamin deficiencies

The prolonged periods of starvation, food restriction (of caloric intake and/or food groups), purging and excessive exercise observed across the ED spectrum have detrimental impacts on micronutrient balances [ 207 ]. The impact of prolonged vitamin deficiencies in early-onset EDs can also impair brain development, substantially reducing neurocognitive function in some younger patients even after weight restoration [ 82 ]. Common micronutrient deficiencies include calcium, fat soluble vitamins, essential fatty acids selenium, zinc and B vitamins [ 183 ]. One included study looked at prevalence rates of cerebral atrophy and neurological conditions, specifically Wernicke's encephalopathy in EDs and found that these neurological conditions were very rare in people with EDs [ 208 ].

Cognitive functioning

The literature included in RR regarding the cognitive changes in ED patients with AN following weight gain was sparse. It appears that some cognitive functions affected by EDs recover following nutritional restoration, whereas others persist. Cognitive functions, such as flexibility, central coherence, decision making, attention, processing speed and memory, are hypothesised to be impacted by, and influence the maintenance of EDs. A systematic review explored whether cognitive functions improved in AN following weight gain [ 83 ]. Weight gain appeared to be associated with improved processing speed in children and adolescents. However, no improvement was observed in cognitive flexibility following weight gain. Further, the results for adults were inconclusive [ 83 ].

Reproductive health

Infertility and higher rates of poor reproductive health are strongly associated with EDs, including miscarriages, induced abortions, obstetric complications, and poorer birth outcomes [ 84 , 85 ]. Although amenorrhea is a known consequence of AN, oligomenorrhea (irregular periods) was common among individuals with BN and BED [ 86 ]. A twin study found women diagnosed with BN and BED were also more likely to have poly cystic ovarian syndrome (PCOS), leading to menstrual irregularities [ 209 ]. The prevalence of lifetime amenorrhea in this sample was 10.4%, and lifetime oligomenorrhea was 33.7%. An epidemiological study explored the association of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) in women with BN and BED and found prevalence rates as high as 42.4% for PMS and 4.2% for PMDD [ 210 ].

Given the increased rates of menstrual irregularities and issues, questions have been raised regarding whether this complication is reversed or improves with recovery. A review of five studies monitoring reproductive functions during recovery over a 6- to 18-year follow up period [ 211 ] noted no significant difference between the pooled odds of childbirth rates between the AN and general population—demonstrating that if patients undergo treatment for AN, achieve weight restoration, and continue to maintain wellness, reproductive functions can renormalise [ 211 ].

An observational study of women with AN, BN or EDNOS found higher rates of low birth rate, pre-term deliveries, caesarean deliveries, and intrauterine growth restrictions [ 84 ]. Increased caesarean delivery was also observed in a large cohort of women diagnosed with BED [ 212 ]. However, these women had higher birth weight babies [ 212 ]. Further, women with comorbid ED and epilepsy were found to have an increased risk of pregnancy-related comorbidities, including preeclampsia (gestational hypertension and signs of damage to the liver and kidneys ) , gestational diabetes and perinatal depression [ 213 ].

The results from this review identified that the symptomology and outcomes of EDs are impacted by both psychiatric and medical factors. Further, EDs have a mortality rate substantially higher than the general population, with a significant proportion of those who die from an ED dying by suicide or as a result of severe medical complications.

This RR noted high rates of psychiatric and medical comorbidities in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, compromised functioning, and adverse treatment outcomes. Evidence suggested that early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and outcomes [ 29 , 35 , 83 ].

EDs and other psychiatric conditions often shared symptoms and high levels of psychopathology crossover were noted. The most prevalent psychiatric comorbidities were anxiety disorders, mood disorders and substance use disorders [ 8 , 100 , 119 ]. perhaps unsurprising given the prevalence of these illnesses in the general population. Of concern is the elevated suicide rate noted across the ED spectrum, the highest observed in AN [ 58 , 140 , 149 ]. For people with AN, suicide attempts were mostly associated with comorbid mood and anxiety disorders [ 136 ]. The review noted elevated rates of NSSI were particularly associated with binge/purge subtype EDs [ 150 ], impulsivity and emotional dysregulation (again, an example of psychopathological overlap).

With regards to PDs, studies were limited to EDs with binge-purge symptomology. Of those included, the presence of a comorbid personality disorder and ED was associated with childhood trauma [ 110 ] and elevated mortality risk [ 111 ]. There appeared to be a link between the clinical characteristics of the ED (e.g., impulsivity, rigidity) and the comorbid PD (cluster B PDs were more associated with BN/BED and cluster C PDs were more associated with AN). There was mixed (albeit limited) evidence regarding the comorbidity between EDs and psychosis and schizophrenia, with some studies noting an association between EDs and psychotic experiences [ 45 ]. Specifically, there was an association between psychotic experiences and uncontrolled eating and food dominance, which were stronger in males [ 122 ]. In addition, the review noted the association between EDs and neurodevelopmental disorders-specifically ADHD—was associated with features of BN and ASD was more prevalent among individuals with AN [ 53 , 54 ] and ARFID [ 55 ].

EDs are complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems that can occur alongside, or result from the ED. The RR noted mixed evidence regarding the effectiveness and safety of enteral feeding [ 180 , 181 ], with some studies noting that RFS could be safely managed with supplementation [ 191 ]. Research also described the impacts of restrictive EDs on BMD and binge eating behaviour on metabolic disorders [ 78 , 195 ]. Purging behaviours, particularly self-induced vomiting [ 79 ], were found to increase the risk of tooth erosion [ 81 ] and damage to soft tissue within the gastrointestinal tract [ 206 ]. Further, EDs were associated with a range of reproductive health issues in women, including infertility and birth complications [ 84 ].

Whilst the RR achieved its aim of synthesising a broad scope of literature, the absence of particular ED diagnoses and other key research gaps are worth noting. A large portion of the studies identified focused on AN, for both psychiatric and medical comorbidities. This reflects the stark lack of research exploring the comorbidities for ARFID, NES, and OSFED compared to that seen with AN, BN and BED. There were no studies identified exploring the psychiatric and medical comorbidities of Pica. These gaps could in part be due to the timeline utilised in the RR search strategy, which included the transition from DSM-IV to DSM-5. The update in the DSM had significant implications for psychiatric diagnosis, with the addition of new disorders (such as Autism Spectrum Disorder and various Depressive Disorders), reorganisation (for example, moving OCD and PTSD out of anxiety disorders and into newly defined chapters) and changes in diagnostic criteria (including for AN and BN, and establishing BED as a discrete disorder). Although current understanding suggests EDs are more prevalent in females, research is increasingly demonstrating that males are not immune to ED symptoms, and the RR highlighted the disproportionate lack of male subjects included in recent ED research, particularly in the domain of psychiatric and medical comorbidities.

As the RR was broad in scope and policy-driven in intent, limitations as a result of this methodology ought to be considered. The RR only considered ‘Western’ studies, leading to the potential of important pieces of work not being included in the synthesis. In the interest of achieving a rapid synthesis, grey literature, qualitative and theoretical works, case studies or implementation research were not included, risking a loss of nuance in developing fields, such as the association and prevalence of complex/developmental trauma with EDs (most research on this comorbidity focuses on PTSD, not complex or developmental trauma) or body image dissatisfaction among different gender groups. No studies regarding the association between dissociative disorders and EDs were included in the review. However, dissociation can co-occur with EDs, particularly AN-BP and among those with a trauma history [ 214 ]. Future studies would benefit from exploring this association further, particularly as trauma becomes more recognised as a risk factor for ED development.

The review was not designed to be an exhaustive summary of all medical comorbidities. Thus, some areas of medical comorbidity may not be included, or there may be variability in the level of detail included (such as, limited studies regarding the association between cancer and EDs). Studies that explored the association between other autoimmune disorders (such as Type 1 Diabetes, Crohn’s disease, Addison’s disease, ulcerative colitis, and coeliac disease) and EDs [ 215 , 216 ] were not included. Future reviews and research should examine the associations between autoimmune disorders and the subsequent increased risk of EDs, and likewise, the association between EDs and the subsequent risk of autoimmune disorders.

An important challenge for future research is to explore the impact of comorbidity on ED identification, development and treatment processes and outcomes. Insights could be gained from exploring shared psychiatric symptomology (i.e., ARFID and ASD, BN/BED and personality disorders, and food addiction). Particularly in disorders where the psychiatric comorbidity appears to precede the ED diagnosis (as may be the case in anxiety disorders [ 28 ]) and the unique physiological complications of these EDs (e.g., the impact of ARFID on childhood development and growth). Further, treatment outcomes would benefit from future research exploring the nature of the proposed reciprocal nature between EDs and comorbidities, particularly in those instances where there is significant shared psychopathology, or the presence of ED symptoms appears to exacerbate the symptoms of the other condition—and vice versa.

The majority of research regarding the newly introduced EDs has focused on understanding their aetiology, psychopathology, and what treatments demonstrate efficacy. Further, some areas included in the review had limited included studies, for example cancer and EDs. Thus, in addition to the already discussed need for further review regarding the association between EDs and autoimmune disorders, future research should explore the nature and prevalence of comorbidity between cancers and EDs. There was variability regarding the balance of child/adolescent and adult studies across the various comorbidities. Some comorbidities are heavily researched in child and adolescent populations (such as refeeding syndrome) and others there is stark child and adolescent inclusion, with included studies only looking at adult samples. Future studies should also address specific comorbidities as they apply to groups underrepresented in current research. This includes but is not limited to gender, sexual and racial minorities, whereby prevalence rates of psychiatric comorbidities are elevated. [ 88 ] In addition, future research would benefit from considering the nature of psychiatric and medical comorbidity for subthreshold and subclinical EDs, particularly as it pertains to an opportunity to identify EDs early within certain comorbidities where ED risk is heightened.

This review has identified the psychiatric and medical comorbidities of EDs, for which there is a substantial level of literature, as well as other areas requiring further investigation. EDs are associated with a myriad of psychiatric and medical comorbidities which have significant impacts on the symptomology and outcomes of an already difficult to treat, and burdensome illness.

Availability of data and materials

Not applicable—all citations provided.


Anorexia nervosa—restricting type

Anorexia nervosa—binge-purge type

Avoidant restrictive food intake disorder

Body mass index

Borderline personality disorder

Diagnostic and statistical manual of mental disorders, 5th edition

Eating disorder

Generalised anxiety disorder

International classification of diseases, 11th edition

Major depressive disorder

Night eating syndrome

Other specified feeding or eating disorder

Post-traumatic stress disorder

Rapid review

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The authors would like to thank and acknowledge the hard work of Healthcare Management Advisors (HMA) who were commissioned to undertake the Rapid Review. Additionally, the authors would like to thank all members of the consortium and consultation committees for their advice, input, and considerations during the development process. Further, a special thank you to the carers, consumers and lived experience consultants that provided input to the development of the Rapid Review and wider national Eating Disorders Research & Translation Strategy. Finally, thank you to the Australian Government—Department of Health for their support of the current project.

National Eating Disorder Research Consortium: Phillip Aouad, Sarah Barakat, Robert Boakes, Leah Brennan, Emma Bryant, Susan Byrne, Belinda Caldwell, Shannon Calvert, Bronny Carroll, David Castle, Ian Caterson, Belinda Chelius, Lyn Chiem, Simon Clarke, Janet Conti, Lexi Crouch, Genevieve Dammery, Natasha Dzajkovski, Jasmine Fardouly, Carmen Felicia, John Feneley, Amber-Marie Firriolo, Nasim Foroughi, Mathew Fuller-Tyszkiewicz, Anthea Fursland, Veronica Gonzalez-Arce, Bethanie Gouldthorp, Kelly Griffin, Scott Griffiths, Ashlea Hambleton, Amy Hannigan, Mel Hart, Susan Hart, Phillipa Hay, Ian Hickie, Francis Kay-Lambkin, Ross King, Michael Kohn, Eyza Koreshe, Isabel Krug, Anvi Le, Jake Linardon, Randall Long, Amanda Long, Sloane Madden, Sarah Maguire, Danielle Maloney, Peta Marks, Sian McLean, Thy Meddick, Jane Miskovic-Wheatley, Deborah Mitchison, Richard O’Kearney, Shu Hwa Ong, Roger Paterson, Susan Paxton, Melissa Pehlivan, Genevieve Pepin, Andrea Phillipou, Judith Piccone, Rebecca Pinkus, Bronwyn Raykos, Paul Rhodes, Elizabeth Rieger, Sarah Rodan, Karen Rockett, Janice Russell, Haley Russell, Fiona Salter, Susan Sawyer, Beth Shelton, Urvashnee Singh, Sophie Smith, Evelyn Smith, Karen Spielman, Sarah Squire, Juliette Thomson, Marika Tiggemann, Stephen Touyz, Ranjani Utpala, Lenny Vartanian, Andrew Wallis, Warren Ward, Sarah Wells, Eleanor Wertheim, Simon Wilksch & Michelle Williams

The RR was in-part funded by the Australian Government Department of Health in partnership with other national and jurisdictional stakeholders. As the organisation responsible for overseeing the National Eating Disorder Research & Translation Strategy, InsideOut Institute commissioned Healthcare Management Advisors to undertake the RR as part of a larger, ongoing, project. Role of Funder: The funder was not directly involved in informing the development of the current review.

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Ashlea Hambleton, Danielle Maloney, Stephen Touyz & Sarah Maguire

School of Health and Social Development, Faculty of Health, Deakin University, Geelong, VIC, 3220, Australia

Genevieve Pepin

Healthcare Management Advisors, Melbourne, VIC, Australia

Sydney Local Health District, Camperdown, NSW, Australia

Danielle Maloney, Stephen Touyz & Sarah Maguire

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National Eating Disorder Research Consortium

  • Phillip Aouad
  • , Sarah Barakat
  • , Robert Boakes
  • , Leah Brennan
  • , Emma Bryant
  • , Susan Byrne
  • , Belinda Caldwell
  • , Shannon Calvert
  • , Bronny Carroll
  • , David Castle
  • , Ian Caterson
  • , Belinda Chelius
  • , Lyn Chiem
  • , Simon Clarke
  • , Janet Conti
  • , Lexi Crouch
  • , Genevieve Dammery
  • , Natasha Dzajkovski
  • , Jasmine Fardouly
  • , Carmen Felicia
  • , John Feneley
  • , Amber-Marie Firriolo
  • , Nasim Foroughi
  • , Mathew Fuller-Tyszkiewicz
  • , Anthea Fursland
  • , Veronica Gonzalez-Arce
  • , Bethanie Gouldthorp
  • , Kelly Griffin
  • , Scott Griffiths
  • , Ashlea Hambleton
  • , Amy Hannigan
  • , Susan Hart
  • , Phillipa Hay
  • , Ian Hickie
  • , Francis Kay-Lambkin
  • , Ross King
  • , Michael Kohn
  • , Eyza Koreshe
  • , Isabel Krug
  • , Jake Linardon
  • , Randall Long
  • , Amanda Long
  • , Sloane Madden
  • , Sarah Maguire
  • , Danielle Maloney
  • , Peta Marks
  • , Sian McLean
  • , Thy Meddick
  • , Jane Miskovic-Wheatley
  • , Deborah Mitchison
  • , Richard O’Kearney
  • , Shu Hwa Ong
  • , Roger Paterson
  • , Susan Paxton
  • , Melissa Pehlivan
  • , Genevieve Pepin
  • , Andrea Phillipou
  • , Judith Piccone
  • , Rebecca Pinkus
  • , Bronwyn Raykos
  • , Paul Rhodes
  • , Elizabeth Rieger
  • , Sarah Rodan
  • , Karen Rockett
  • , Janice Russell
  • , Haley Russell
  • , Fiona Salter
  • , Susan Sawyer
  • , Beth Shelton
  • , Urvashnee Singh
  • , Sophie Smith
  • , Evelyn Smith
  • , Karen Spielman
  • , Sarah Squire
  • , Juliette Thomson
  • , Marika Tiggemann
  • , Stephen Touyz
  • , Ranjani Utpala
  • , Lenny Vartanian
  • , Andrew Wallis
  • , Warren Ward
  • , Sarah Wells
  • , Eleanor Wertheim
  • , Simon Wilksch
  •  & Michelle Williams


DM, PM, ST and SM oversaw the Rapid Review process; AL carried out and wrote the initial review; AH and GP wrote the first manuscript; all authors edited and approved the final manuscript.

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Correspondence to Ashlea Hambleton .

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Competing interests.

ST receives royalties from Hogrefe and Huber, McGraw Hill and Taylor and Francis for published books/book chapters. He has received honoraria from the Takeda Group of Companies for consultative work, public speaking engagements and commissioned reports. He has chaired their Clinical Advisory Committee for Binge Eating Disorder. He is the Editor in Chief of the Journal of Eating Disorders. ST is a committee member of the National Eating Disorders Collaboration as well as the Technical Advisory Group for Eating Disorders. AL undertook work on this RR while employed by HMA. A/Prof Sarah Maguire is a guest editor of the special issue “Improving the future by understanding the present: evidence reviews for the field of eating disorders.”

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Supplementary Information

Additional file 1..

PRISMA diagram.

Additional file 2.

Studies included in the Rapid Review.

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Hambleton, A., Pepin, G., Le, A. et al. Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. J Eat Disord 10 , 132 (2022). https://doi.org/10.1186/s40337-022-00654-2

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DOI : https://doi.org/10.1186/s40337-022-00654-2

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    A literature review can be a part of a research paper or scholarly article, usually falling after the introduction and before the research methods sections. ... If you choose this strategy, be careful to avoid simply listing and summarizing sources in order. Try to analyze the patterns, turning points, and key debates that have shaped the ...

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