During the time of Caesar, rich ancient Romans overindulged at lavish banquets and then vomited so they could return and continue eating. Ancient Egyptians drew hieroglyphics that depicted their use of monthly purges to avoid illness. Chinese scrolls originating in the early Dynasties described ailments that were very similar to modern eating disorders. Tribal lore from Africa contains several stories of adults fasting during extreme times of famine in order to save food for their children (and then continuing to restrict their diet to the point of being in danger of death even after the famine was over).
During the Middle Ages and the early Renaissance periods, spiritually motivated self-starvation appeared with women who fasted to acquire the status of Saints in the Roman Catholic Church. However, in the 17th and 18th centuries, the belief formed that starving oneself was due to being possessed by the devil. Most noteworthy about these original descriptions of eating disorders is the lack of ‘a fear of fat’ – seen presently in the central diagnosis of anorexia nervosa and bulimia.
The first formal description and diagnosis of anorexia was documented in England during the 1690s. Historical records indicate that a Dr. Richard Morton described a patient as ‘a skeleton clad with skin’ and suggested that her sadness ate away at her. Unfortunately, there are no other historical mentions of anorexia until the 19th century when almost simultaneously two physicians, Sir William Gull and Ernest-Charles Lasegue, described cases of the disorder in 1873. Both physicians created a list of psychosomatic symptoms, however, they presented different causes for the disorder.
Sir William Gull, a physician to England’s royal family, termed the condition anorexia nervosa, meaning loss of appetite, and believed the disorder occurred in both males and females. Viewing the disorder from a medical point of view, he observed that anorexia was mostly found in young girls, 16-23 years old, and its characteristic symptom was fatigue. He treated patients by prescribing force-feeding, moral teaching and a change of scene. French psychiatrist, Ernest-Charles Lasegue used the term anorexia hysterique or hysteric anorexia, describing the illness from a social and psychological point of view. He emphasized the role of the family as contributing to the disorder believing the disease could develop only in comfortable homes with an abundance of food (for example, at mealtime, children are expected to finish their food which can cause stress leading them to refuse to eat as a form of rebellion). Lasegue also believed that it was more prevalent among women who found their lives suffocating and could not display emotional distress so they protested by not eating.
Both doctors included a stance on the family’s impact on the disorder, suggesting that the family environment had a contributory role in the development of the illness. Their descriptions started a debate in the literature on anorexia nervosa about whether it was possible to treat the patient without isolating her from her family. During the first half of the 20th century the family continued to be seen primarily as a hindrance to treatment, leading to the exclusion of parents from treatment – referred to as a “parentectomy”.
In 1903, Pierre Janet published the first detailed descriptions of patients with bulimia. In “Obsessions et al Psychasthenie”, Janet described Nadia, a woman who engaged in compulsive binges in secret. At this time, anorexia and bulimia were being thought of as physical diseases due to a medical condition. Researchers would attribute these disorders to hormone imbalances and endocrine deficiencies (specifically Simmond’s disease which consists of lack an of pituitary gland functioning). Physicians also thought that anorexia was a form of tuberculosis.
It wasn’t until the 1930’s that the medical community began to understand the underlying psychological and emotional aspects of eating disorders with the help of the case study of Ellen West (1930-1933). Ellen West, the pseudonym for a patient of the Swiss psychiatrist Ludwig Binswanger, was in her twenties when she began suffering from depressive spells. At the age of 21, she developed an extreme fear of ‘becoming fat’ due to teasing from her friends who mocked her for having gained weight during a trip to Sicily. The paper provided West’s perspective, with the help of diary entries, describing her obsession with food and thinness. The case study proved that eating disorders can have multiple causation factors, including social and cultural triggers. This, as a result, changed perceptions regarding treatment.
In the 1960s, the medical community began to see a major shift concerning the role of the family on eating disorders. Salvador Minuchin and his colleagues at the Child Guidance Center in Philadelphia suggested the importance of the family in the development and reinforcement of psychosomatic symptoms in children. Though Minuchin did not place the blame directly on parents, he did hypothesize that anorexia developed in a dysfunctional family – one characterized by rigidity, inadequate personal boundaries, over-involvement and conflict avoidance. He suggested treatment involving the family, aimed at changing the way the family functioned.
Research has since shown that family environment does not cause the illness. However, as an eating disorder can undermine family life, and as a result recovery; modern treatment providers have evolved the concept of family therapy to be about working with the family’s strengths. Results from studies performed at the Maudsley Hospital in London, which was replicated in the United States, has shown that outcomes appear much better if parents are empowered and included in treatment. In fact, a carefully controlled trial evaluating the effectiveness of a family-based treatment approach found that 50% of its participants continued to experience full remission one year after the end of therapy – suggesting that family involvement can be critical to recovery. While it was encouraging to have new and effective treatments, the world’s understanding of these two disorders was still relatively unknown as they became society’s ‘secret illness’ due to the associated feelings of embarrassment.
FROM HOLLYWOOD TO DORMITORIES
In 1978, Hilde Bruch’s The Golden Cage was one of the first books to suggest that eating disorders were becoming a serious problem. Subsequently, the first clinical documentation of bulimia was a paper published in 1979, the result of the research that overeating and self-induced vomiting may have been common practices among otherwise normal female students attending North American universities. In 1983, popular singer and drummer Karen Carpenter died of heart failure brought on by her anorexia. This became an important event in the timeline of eating disorders as her death prompted widespread ongoing medical coverage on eating disorders.
In the 1990s, binge eating disorder was first recognized as a formal diagnosis. Prior to 1992, when binge eating disorder was officially introduced at the International Eating Disorders Conference, individuals with this type of behavior were labeled emotional overeaters, compulsive overeaters and food addicts. The 21st Century has seen an evolution in the treatment of eating disorders as interventions began to encompass a holistic approach that addressed multiple aspects, including psychological, medical and nutritional – aiding in the increased number of individuals successfully recovering these disorders.
- Engel PsyD, Bridget; Reiss PhD., Natalie and Dombeck Ph.D., Mark. Eating Disorders Historical Understandings. MentalHelp.net
- Insel, Thomas. Post by Former NIMH Director Thomas Insel: Spotlight on Eating Disorders. National Institute of Mental Health. 2012.
- Miller, MD., Merry. Culture and Eating Disorders. Psychiatric Times 16(2). Feb 1999. https://www.psychiatrictimes.com/articles/culture-and-eating-disorders
- Miller, MD., Merry and Pumariega, Andres. Culture and Eating Disorders: A Historical and Cross-Cultural Review. Psychiatry 64(2). Summer 2001.
- National Eating Disorders Association. Health Consequences of Eating Disorders. 2012.
- Niedzielski, Antoni; Kazmierczak, Natalia and Grzybowski, Andrzej. Sir William Withey Gull (1816-1890). Journal of Neurology. 2017; 264(2): 419-420.
- Petre, MS, Alina. 6 Common Types of Eating Disorders (and Their Symptoms). HealthLine. Sept 2017
- Schwarz, Julian. Burkhart Brückner (2016): West, Ellen. Biographisches Archiv der Psychiatrie.
- Tancrdi, Sofia. Anorexia Through the Ages: From Sainthood to Psychiatry. eiblanance. March 2013