History

The extent to which people suffered from anorexia nervosa in the past has been a subject of much historical debate. Some clinicians and medical historians have suggested that anorexia nervosa was first identified in 1689 by the British doctor Richard Morton, physician to James II (Bliss and Branch 1960; Silverman 1983). The medieval historian Rudolph Bell (1985) has dated the origins of anorexia nervosa even earlier, claiming that the medieval female saints, who were reputed to live without eating anything except the Eucharist, actually suffered from anorexia nervosa.

Other historians, however, have argued that attempts to label all historical instances of food refusal and appetite loss as anorexia nervosa are simplistic and maintain that the historical record is insufficient to make conclusive diagnoses of individual cases (Bynum 1987; Brumberg 1988). Although these historians agree that the final physiological stage of acute starvation may be the same in contemporary anorectics and medieval ascetics, the cultural and psychological reasons behind the refusal to eat are quite different. Thus, to reduce both to a single biomedical cause is to overlook the variety of social and cultural contexts in which certain individuals have chosen to refuse food.

The modern disease classification of anorexia nervosa emerged during the 1860s and 1870s, when the work of public asylum keepers, elite British physicians, and early French neurologists partially distinguished anorexia nervosa from other diseases involving loss of appetite (Brumberg 1988). In 1859, the American asylum physician William Stout Chipley published the first American description of sitomania, a type of insanity characterized by an intense dread or loathing of food (Chipley 1859). Although Chipley found sitophobia in patients from a broad range of social groups and age-groups, he identified a special form of the disease that afflicted adolescent girls.

Chipley’s work was ignored by his contemporaries, however, and it was not until the 1870s, when two influential case studies by the British physician William Withey Gull and the French alienist Charles Lasegue (Lasegue 1873; Gull 1874) were published, that physicians began to pay significant attention to anorexia in girlhood. Gull’s primary accomplishment was to name and establish anorexia nervosa as a coherent disease entity, distinct from mental illnesses in which appetite loss was a secondary feature and from physical “wasting” diseases such as tuberculosis, diabetes, or cancer. Despite widespread acclaim for Gull’s work with anorexic patients, however, late-nineteenth-century clinicians generally rejected the conception of anorexia nervosa as an independent disease. Instead, they viewed it either as a variant of hysteria that affected the gastrointestinal system or as a juvenile form of neurasthenia (Brumberg 1988).

Nineteenth-century physicians also tended to focus on the physical symptom of not eating and ignored the anorexic patient’s psychological reasons for refusing food. An important exception was Lasegue, who was the first to suggest the significance of family dynamics in the genesis and perpetuation of anorexia nervosa. Because of the somatic emphasis of nineteenth-century medicine, however, most medical practitioners of that time disregarded Lasegue’s therapeutic perspective. Instead, they directed medical intervention toward restoring the anorectic to a reasonable weight and pattern of eating rather than exploring the underlying emotional causes of the patient’s alleged lack of appetite (Brumberg 1988).

In the twentieth century, the treatment of anorexia nervosa changed to incorporate new developments within medical and psychiatric practice. Before the Second World War, two distinct and isolated models dominated medical thinking on anorexia nervosa. The first approach was rooted in late-nineteenth-century research in organotherapy, a form of treatment based on the principle that disease resulted from the removal or dysfunction of secreting organs and glands (Brumberg 1988). Between 1900 and 1940, a variety of different endocrinologic deficiencies were proposed as the cause of anorexia nervosa. In 1914, Morris Simmonds, a pathologist at the University of Hamburg, published a clinical description of an extreme cachexia due to destruction of the anterior lobe of the pituitary. Because patients with anorexia nervosa and those with Simmonds’s disease shared a set of common symptoms, many clinicians assumed that a deficiency in pituitary hormone was the cause of both conditions (Brumberg 1988).

Other researchers implicated thyroid insufficiency as the cause of anorexia nervosa. Research conducted at the Mayo Clinic in Rochester, Minnesota, during the period between the two world wars established the relationship between thyroid function and body weight and led many physicians to regard anorexia nervosa as a metabolic disorder caused by a deficiency in thyroid hormone. Throughout the 1920s and 1930s, insulin, antuitrin, estrogen, and a host of other hormones were also employed in the treatment of anorexia nervosa (Brumberg 1988).

The second major approach to anorexia nervosa in the early twentieth century grew out of the field of dynamic psychiatry, which emerged during the 1890s and early 1900s. Beginning in the last decade of the nineteenth century, practitioners in dynamic psychiatry increasingly focused on the life history of individual patients and the emotional sources of nervous disease. Two of the leading pioneers in this new field - Sigmund Freud and Pierre Janet - were the first to suggestively link the etiology of anorexia nervosa with the issue of psychosexual development. According to Freud, all appetites were expressions of libido or sexual drive. Thus, not eating represented a repression of normal sexual appetite (Freud 1959). Similarly, Janet asserted that anorexic girls refused food in order to retard normal sexual development and forestall adult sexuality (Janet 1903).

Because of the enormous popularity of endocrino-logic explanations, the idea of anorexia nervosa as a psychosexual disturbance was generally overlooked for more than 30 years. By the 1930s, however, the failure of endocrinologic models to establish either a predictable cure or a definitive cause of anorexia nervosa, the growing reputation of the Freudian psychoanalytic movement, and increased attention to the role of emotions in disease led a number of practitioners to assert the value and importance of psychotherapy in the treatment of anorexia nervosa. Although biomedical treatment of the disorder continued, most clinicians argued that successful, permanent recovery depended on uncovering the psychological basis for the anorectic’s behavior. Following up on the work of Freud and Janet, orthodox psychiatrists during this time postulated that refusal to eat was related to suppression of the sexual appetite and claimed that anorexic women regarded eating as oral impregnation and obesity as pregnancy (Brumberg 1988).

After World War II, a new psychiatric view of eating disorders, shaped largely by the work of Hilde Bruch, encouraged a more complex interpretation of the psychological underpinnings of anorexia nervosa. Although Bruch agreed that the anorectic was unprepared to cope with the psychological and social consequences of adulthood and sexuality, she also stressed the importance of individual personality formation and factors within the family that contributed to the psychogenesis of anorexia nervosa. Here, Bruch revived Lasegue’s work on the role of family dynamics in anorexia nervosa. According to Bruch, the families of most anorexic patients were engaged in a dysfunctional style of familial interaction known as “enmesh-ment”: Such families are characterized by extreme parental overprotectiveness, lack of privacy of individual members, and reluctance or inability to confront intrafamilial conflicts. Although superficially these families appeared to be congenial, Bruch wrote, this harmony was achieved through excessive conformity on the part of the child, which undermined the child’s development of an autonomous self. Anorexia nervosa, according to Bruch, was therefore a young woman’s attempt to exert control and self-direction within a family environment in which she otherwise felt powerless (Bruch 1973,1988).

Bruch was also primarily responsible for the tremendous growth in the popular awareness of anorexia nervosa and other eating disorders in the 1970s and 1980s. Through her book, The Golden Cage: The Enigma of Anorexia Nervosa (1978), which sold over 150,000 copies, and numerous articles in Family Circle and other popular magazines, Bruch brought anorexia nervosa into common. American parlance.

At the same time that the American public was becoming increasingly aware of anorexia nervosa, the number of reported cases of the disorder grew tremendously. This phenomenon has led some clinicians and social commentators to suggest that the popularization process itself may promote a “sympathetic host environment” for the disorder (Striegel-Moore, Silberstein, and Rodin 1986). As Bruch herself observed: “Once the discovery of isolated tormented women, it [anorexia nervosa] has now acquired a fashionable reputation, of being something to be competitive about. . . . This is a far cry from the twenty-years-ago anorexic whose goal was to be unique and suggests that social factors may impact the prevalence of the disorder” (Bruch 1988: 3-4).