In the late 1800s, the curtain was about to rise on modern conceptions of anxiety. Victorians were beginning to get a glimpse of a new world, a world characterized by radical transformations, such as the telegraph, new theories of evolution and religion, telephones, light bulbs, elevators, and new forms of transportation. Such transformations seemed to produce a special kind of fear, a fear that we might call today general anxiety. Among burgeoning attention to the study of “mental states,” such as William James’ seminal work Principles of Psychology and Freud’s theory of the unconscious mind, Victorian doctors increasingly noted a rise in a previously obscure disorder called "hysteria."

Hysteria, from the Greek hysterikos (“of the womb”) was mainly associated with women and was indeed thought to be caused by a dysfunction of the uterus (Stacey 2002). The symptoms, mostly exhibited by women, were physical, but they also seemed to be linked to psychological factors and emotional distress. Increasingly, hysteria was seen as a type of social illness that was directly related to the needs and style of the era. In fact, soon after the turn of the century, cases of hysteria declined as social transformations were established, including significant changes in the status of women (Gordon 2000). Yet, in the second half of the twentieth century, a different and more serious type of “anxiety” burst into public view: eating disorders, namely anorexia nervosa, bulimia nervosa, and binge eating disorder.

Anorexia Nervosa

Indeed, “anorexia nervosa” as a term is a relatively new, but as a clinical entity it can be traced back hundreds of years. During the twelfth and thirteenth centuries, dominant interpretations of self-starvation were religious, particularly in Western Christianity. Women who starved themselves (“miracle maidens”) were highly esteemed, and the origins of their “holy anorexia” were thought to be supernatural. One well known example of a fasting woman was Catherine of Siena (1347-80) who was regarded as a saint. For Catherine, complete control over her body was a sign of devotion (Heywood 1996). In her eyes, to yield to food was to yield to sin and, ultimately, to deceive God.

The fasting practices of female saints such as Catherine approximate the practices involved in self-denial of food by women diagnosed with anorexia nervosa in the late twentieth century. And for some scholars, the intense relationship between medieval women and holiness is analogous to modern women and thinness such that holiness and thinness are ideal states of being in a struggle to assert female identity. The period of “holy anorexia,” however, was short lived, and in the sixteenth century, the church no longer tolerated asceticism. Anorexics were, in fact, condemned as witches and consigned to the stake (Brumberg 2000).

In 1689, English physician Richard Morton describes in his Phtisiologia: a Treatise on Consumption two cases of a “wasting” disease of nervous origins that could be considered the first clear medical description of anorexia nervosa in both men and women (Gordon 2000). In addition, though clinical cases of wasting disease were described by other physicians--such as Baglivi in the early 1700s, Robert Whytt in 1764, Louis-Victor Marce in 1860, and Charles Laseque--anorexia nervosa became the focus of intense medical attention only when prominent physician to Queen Victoria, Sir William Gull (1816-1890), published his text Anorexia Hysterica. Gull coined the term anorexia nervosa to distinguish the disorder from the umbrella term “hysteria.” His conclusion that anorexia nervosa was a psychological disorder was immensely significant (Hepworth 1999). Previously, self-starvation was associated with different traditions like theology or folklore, but his work moved the study of anorexia nervosa into the field of psychiatry.

From the 1920s to the 1930s, anorexia nervosa nearly dropped out of psychiatric discussion, perhaps due to the diagnosis of a newly discovered endocrine disease whose symptoms seemed, at first, similar to anorexia nervosa. Morris Simmonds, a pathologist from Hamburg, described a case of cachexia (physical wasting) that he attributed to a lesion in the anterior lobe of the pituitary gland in 1914. Simmond’s Disease, as it became known, was treated using endocrine treatments such as pituitary extracts. These patients undoubtedly included an unknown number of patients with anorexia nervosa, particularly because in the 1920s the ultra-slim, androgynous images of the flapper dominated American fashion. Due to this confusion, little progress was made in understanding anorexia nervosa as a psychological disorder. It was not until the late 1930s that psychiatrists and physicians were able to clearly differentiate between the endocrine disease that gives rise to wasting away and anorexia nervosa (Hepworth 1999).

During the 1940s, psychological theorizing, particularly psychoanalytic interpretations about anorexia nervosa, reappeared in earnest. These interpretations argued that the origins of anorexia nervosa were sexual (Hepworth 1999). However, traditional psychoanalytical views which focused almost exclusively on sexual factors proved to be of little value to anorexic patients. While these theories find little acceptance today, they did help return anorexia into psychological discussions (Brumberg 2000).

Singer Karen Carpenter died of anorexia nervosa, aged 32

Anorexia nervosa continued to rapidly increase into the next decade and became known as the “disorder of the 80s,” suggesting that diseases, particularly psychiatric disorders, are often directly linked to cultural contexts (though some aspects of anorexia exhibits both noncultural and cultural incidences). By the mid 1980s, college campuses instituted counseling or support systems, and public awareness reached a peak when popular singer Karen Carpenter died of cardiac arrest.

Bulimia

The term “bulimia” (“bous”-ox, “limous”-hunger) nervosa entered the English language in 1977 in the sense of the modern disorder. It is a disorder characterized by the rapid consumption of food followed by attempts to purge the body of the food via vomiting, laxatives, or excessive exercise. Bulimia is known by multiple names, such as bulimarexia, binge-purge syndrome, dietary chaos syndrome, and bulimia nervosa...perhaps representing lingering uncertainty about its essence and relationship to anorexia (Gordon 2000). There is no question, however, that it increased in the late 1970s and 1980s and can often be found in the advanced stages of anorexia nervosa.

While gluttony was one of the medieval seven deadly sins reviled by the Catholic church, food insecurity often led to uncontrolled consumption during times of plenty. Furthermore, wealthy families in the Middle Ages would vomit during meals because consuming large amounts of food was seen as a sign of wealth. Nineteenth century reports describe 22 patients who overate due to head injury, brain disease, or epilepsy. These examples, however, show little evidence of a preoccupation with thinness and are unlikely examples of the modern eating disorder. In fact, the existence of bulimia nervosa as a distinct disorder prior to the twentieth century is highly unlikely...and even within the twentieth century, it did not emerge with full force until the 1970s (Gordon 2000).

There are, however, a small number of cases of bulimia in the early twentieth century. Ludwig Bins Wanger’s famous patient, Ellen West, exhibited some traits of bulimia, such as binging and purging and abusing laxatives to keep thin. A second early case was Pierre Janet’s 1903 patient Nadja, who exhibited a bulimic form of anorexia. In the 1930s, bulimia was reported as a symptom of emotional deprivation and poor social adaptation, especially among immigrants. It wasn’t until the 1970s that bulimia would emerge in epidemic proportions, not only in the U.S. but also in England, France, and Germany. The first detailed description was given in 1976 by Marlene Boskind-Lodall, but because she published it in a feminist journal rather than a psychiatric one, her work was not known in the professional community.

The first formal clinical paper that remains the definitive work in the study of bulimia was psychiatrist Gerard Russell’s 1979 article “Bulimia Nervosa: An Ominous Variant of Anorexia Nervosa.” Russell notes that both anorexia and bulimia nervosa are developmental disorders and share a characteristic fear of fatness and body image (Vogler 1993). But bulimia is different in that bulimia tends to develop later than anorexia; bulimics were more likely to not lose as much weight. In addition, Russell noted that bulimics tended to be more extrovertive, impulsive, and even more promiscuous. He also pointed to the dangers of bulimia, including loss of electrolytes, erosion of teeth enamel (due to repeated exposure to acidic gastric contents), cavities, stomach ulcers, stomach or esophagus ruptures, constipation, irregular heartbeat, and an increased tendency toward suicidal behavior (Gordon 2000).

Controversy over how bulimia should be defined and diagnosed characterized the 1980s. For example, scholars argued whether binge eating or purging was the primary role. These issues and more were resolved in DSM-III-R in 1987. Bulimia has been treated with various methods such as cognitive-behavior therapy, interpersonal therapy, psychodynamic approaches and, more recently, antidepressants.

Binge Eating Disorder and Obesity

While various forms of anorexia nervosa, bulimia nervosa, and BED have existed throughout history, it was only during the late nineteenth century that eating disorders appeared in their modern sense. Like nineteenth century forms of “hysteria,” eating disorders also draw on the common cultural vocabulary of their time such as modern obsessions of food that have become endemic in advanced industrial societies. Sufferers of eating disorders also draw on cultural preconceptions to escape or control emotional stress. The sudden peak of eating disorders in the 1970s and 1980s is multifaceted, but scholars point to changing fashion trends, changing bust-to-waist ratios of female models, the interplay of biological and socioeconomic factors, the prevalence of dieting behaviors, increasing pressures to compete and perform, and increased rates of depression and OCD.

Perhaps the contemporary epidemic of eating disorders will markedly decrease just as “hysteria” did in the early twentieth century as people with eating disorders, particularly women, are able to hold more power in the world regardless of their body type. Already some scholars are suggesting the worst has come and gone (Gordon 2000). But given the cultural saturation with issues of weight and identity, it is hard to predict what new vocabulary of anxiety will surround the body next.

-- Posted August 8, 2008

References

Brumberg, Joan Jacobs. 2000. Fasting Girls: The History of Anorexia Nervosa. New York, NY: Vintage Books.

Gordon, Richard A. 2000. Eating Disorders: Anatomy of a Social Epidemic. 2^nd ed. Malden, MA: Blackwell Publishers, Ltd.

Hepworth, Julie. 1999. The Social Construction of Anorexia Nervosa. Thousand Oaks, CA: Sage Publications, Ltd.

Heywood, Leslie. 1996. Dedicated to Hunger: The Anorexic Aesthetic in Modern Culture. Berkeley, CA: University of California Press.

Stacey, Michelle. 2002. The Fasting Girl: A True Victorian Medical Mystery. New York, NY: Penguin Putnam, Inc.