History of Eating Disorders

Are Eating Disorders a Modern Illness?

Diagnostic History of Eating Disorders
Photo by Rebecca Muhlheim.

Given the current sociocultural fixation with thinness, you could reasonably conclude that eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorder, are relatively recent phenomena. However, historical evidence shows eating disorders have been around for quite some time—albeit maybe in somewhat different forms.

The Historical Record

The earliest historical descriptions of people experiencing symptoms consistent with modern-day eating disorders date back to Hellenistic (323 BC-31 BC) and medieval times (5th -15th century AD).

Around this time, purification through the denial of physical needs and the material world emerged as a cultural theme.

There is a report of an upper class twenty-year-old Roman girl starving herself to death in pursuit of holiness. There are additional accounts from the Middle Ages of extreme self-induced fasting that often led to premature death by starvation— Catherina of Siena is one example.

Deprivation of food was seen as a spiritual practice and women were disproportionately afflicted. Some contemporary authors have dubbed these fasting habits “holy anorexia.”

The motivation for this fasting seems to be different than the drive for thinness that dominates today’s discussions of eating disorders. Despite this, many believe that this is the same disorder, merely assuming different cultural meanings based on the sociocultural climate.

History of Anorexia Nervosa

In 1689, English physician Richard Morton described two cases of “nervous consumption” —one in a boy and one in a girl. These are considered the earliest modern cases of the illness we now know as anorexia nervosa. He described the lack of a physical explanation for the loss of appetite and wasting and hence, determined “this Consumption to be Nervous.”

The next cases reported were about 200 years later. In 1873, Sir William Gull, another English physician, coined the term “anorexia nervosa” in published case reports. Also, in 1873, a French physician, Ernest Charles Lasegue published descriptions of individuals with “anorexie hysterique.”

The American doctor Hilde Bruch greatly influenced the understanding of modern anorexia nervosa. She published numerous articles and books. It was at this time that anorexia became more widely known.

More recent research has advanced our knowledge and some of Dr. Bruch’s ideas—such as those that implicate early family dynamics as causing the disorder—are now considered outdated. Earlier psychoanalytic explanations of the illness have been replaced as our understanding of the genetic and biological processes have increased.

Researchers Keel and Klump (2003) propose that the differing motivations for food refusal across historical time periods may represent culturally meaningful ways to understand a disorder that leaves people—disproportionately, females—feeling unable and unwilling to eat.

History of Bulimia Nervosa

In contrast to anorexia nervosa—which appears to have been noted throughout history—bulimia nervosa appears to be a more modern development. Bulimia nervosa was first described as a variant of anorexia in 1979 by British psychiatrist, Gerald Russell.

Russell himself believed that bulimia nervosa was a culture-bound condition and did not believe that extrapolating to historical cases of overeating and vomiting were relevant to our modern understanding of the disorder. Nevertheless, purging was a practice in ancient Egypt, Greece, Rome, and Arabia, cultures in which it was used to prevent diseases believed to come from food. Physicians also prescribed it. Some early Roman emperors were observed to eat to excess and then vomit. Some writers have disagreed with Russell and propose this behavior was an early historical variant of bulimia nervosa, lacking—as in the case of the early accounts of anorexia nervosa—the modern drive for thinness.

Searches for descriptions of bulimia nervosa in the early medical literature have been less fruitful than those for anorexia nervosa.

Among the earliest cases that bear a clear resemblance to modern bulimia nervosa is the case of Nadia, described by Pierre Janet in 1903. She displayed dietary restriction, fear of fatness, and episodes of binge eating.

Another early description, the case of Patient D, was described by Mosche Wulff in 1932. This patient engaged in periods of fasting alternating with periods of overeating and vomiting.

In 1960 US psychiatrists Bliss and Branch published case histories that included a number of cases of bingeing and vomiting. The German psychiatrist Ziolko published papers in the 1970s describing patients who engaged in compulsive food intake and vomiting and experienced increased weight concerns.

The 1970s spawned case reports of patients with what more clearly resembles modern-day bulimia nervosa. Gerald Russell published his case series of 30 patients between 1972 and 1978 who reported self-induced vomiting as an attempt to mitigate the effects of episodes of overeating. It was determined that these represented a syndrome that was distinct from anorexia nervosa but shared the same fear of fatness.

His famous paper, published in 1979, called bulimia nervosa “an ominous variant of anorexia nervosa.” In 1976, Christopher Fairburn also saw an early case of bulimia nervosa and began studying it and developing a treatment for it. The disorder was barely heard of prior to the latter half of the 20th century; since then, it has become relatively common.

History of Binge Eating Disorder

Binge eating disorder was even later on the scene. Binge eating disorder was first described in 1959 by psychiatrist Albert Stunkard, who coined the term “Night Eating Syndrome”. He later specified that binge eating could occur without the nocturnal component of that disorder. Binge eating disorder was first studied in weight loss populations.

In 1993 a cognitive behavioral therapy manual for binge eating and bulimia nervosa was published by Fairburn, Marcus, and Wilson. This manual described how cognitive behavioral therapy could effectively treat bulimia nervosa and binge eating disorder. It went on to become the most studied manual for the treatment of eating disorders

Diagnostic History

The three major disorders entered the Diagnostic and Statistical Manual in the same order.

Anorexia nervosa was accepted as a psychological disorder in the late 1800s after the early reports recounted above. In 1952, it earned a place in the first edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-I), the first eating disorder to do so. However, it was officially categorized: “006-580 Psychophysiologic gastrointestinal reaction” in a broad category that included gastrointestinal disorders such as peptic ulcers, chronic gastritis, and ulcerative colitis. The common factor was that emotional factors were believed to play a causal role.

The DSM’s second edition (DSM-II) was published in 1968. Anorexia was categorized under Special Symptoms (306). “This category is for the occasional patient whose psychopathology is manifested by discrete, specific symptoms. An example might be anorexia nervosa under Feeding disturbance as listed below. It does not apply, however, if the symptom is the result of an organic illness or defect or other mental disorder. For example, anorexia nervosa due to schizophrenia would not be included here.”

Other diagnoses in this category in the DSM-II included:

306.0 Speech disturbance

306.1 Specific learning disturbance

306.2 Tic

306.3 Other psychomotor disorder

306.4 Disorder of sleep

306.5 Feeding disturbance

306.6 Enuresis

306.7 Encopresis

306.8 Cephalalgia

306.9 Other special symptom

In the DSM-III (1980), Eating Disorders debuted as a diagnostic category under the rubric of disorders of infancy, childhood, or adolescence. Bulimia—not yet called bulimia nervosa—made its first appearance in this edition. The other eating disorders included in DSM-III were anorexia nervosa, pica, rumination disorder, and atypical eating disorder.

With the publication of the DSM-IV in 1994, bulimia nervosa appeared in its current form, with the required feature of shape and weight concerns. Binge eating disorder (BED) was also mentioned for the first time. At this point, BED was still not known as an independent disorder but included in an appendix as a proposed diagnosis for future study.

In this edition, Anorexia Nervosa and Bulimia Nervosa were moved out of the disorders of infancy, childhood, or adolescence and became their own—Eating Disorders—while the other disorders (pica, rumination disorder, and feeding disorder of infancy or early childhood) remained in the category Feeding and Eating Disorders of Infancy or Early Childhood.

Binge eating disorder finally made an appearance as an independent diagnosis in the DSM-5 in 2013. The categories of “Eating Disorders” and “Feeding and Eating Disorders of Infancy or Early Childhood” were reunited in the new umbrella category, Feeding and Eating Disorders. The DSM-5 also included avoidant restrictive food intake disorder (ARFID), for the first time. It replaced Feeding Disorder of Infancy or Early Childhood.

In Summary

While anorexia nervosa appears to have existed for centuries and to take on meaning according to the sociocultural context, bulimia nervosa is believed to be a more modern disorder influenced by sociocultural factors, specifically the intensified idealization of thinness and the increased availability of high-density foods. Binge eating relies on large stores of readily edible food so is limited to places and periods with abundant food. Purging appears limited to a context in which prevention of weight gain is culturally meaningful.

Our understanding of these illnesses continues to expand and evolve. We now know they are complex illnesses caused by an interplay of genetic and environmental factors. We recognize that the affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.

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By Lauren Muhlheim, PsyD, CEDS
 Lauren Muhlheim, PsyD, is a certified eating disorders expert and clinical psychologist who provides cognitive behavioral psychotherapy.