A Historical Perspective on the Cultural Connotations Surrounding Eating Disorders

Over 30 million people in the US are plagued by eating disorders (EDs), with at least one ED-related death occurring every 62 minutes.[1] These serious illnesses, which have the greatest mortality rate of any psychological disorder, are characterized by abnormal eating patterns. Of all EDs, the two most well-known are anorexia nervosa, which consists of severe restriction in calories to achieve weight loss, and bulimia nervosa, in which purging follows periodic episodes of binge eating. While the diagnosis of the first eating disorder, “anorexia nervosa,” was not coined until 1873 by English physician William Gull, “disordered” eating behaviors as per current medical qualifications—most notably, self-induced starvation, binging, and purging—have a history that extends long before that. I argue that historical sightings of disordered eating behaviors in the past were not eating disorders.[2] The cultural connotations in those time periods of the refusal of food, binging, and purging were distinctly different than they were following the creation of anorexia nervosa as a diagnosis, and both are unlike our understanding of eating disorders today.

English physician William Gull named the first eating disorder, anorexia nervosa (AN), a disease in his 1873 journal article, “Anorexia Hysteria (Apepsia Hysterica, Anorexia Hysterica).” A century later, the British psychiatrist Gerald Russell, in 1979, coined the diagnosis “bulimia nervosa” (BN), characterizing it in his paper as “an ominous variant of anorexia nervosa.” The DSM-III in 1980 eventually added the diseases “Anorexia Nervosa” and “Bulimia” as mental disorders in a section entitled, “Eating Disorders.” The DSM-III-R (1987) later modified the diagnosis “Bulimia” to “BulimiaNervosa,” the name Russell gave the ED in his paper, with the criteria of the disease altered to make it more specific.3 The current DSM-V manual continues to qualify AN and BN as EDs.

Today, the DSM-V, used to diagnose AN and BN, lists the body image of the patient—for the former, “a disturbance in the way in which one’s body weight or shape is experienced,” and for both, a “self-evaluation [by the patient] that is unduly influenced by body weight or shape”—as part of the “diagnostic criteria” and one of the three “essential features” of both EDs.4 The idea of body image of the patient as a cause of disordered eating patterns, however, is entirely absent from many past accounts of these behaviors, particularly in the period before 1873, a time when EDs were not a disease. In fact, the possibility that an individual could starve, binge, or purge intentionally to lose weight did not exist. This paper discusses the characterization and perception of disordered eating behaviors—specifically, self-induced starvation, binging, and purging—in three periods: before 1873, a time when the medical community did not consider EDs a disease; between 1873 until around the 1970s or 1980s, when physicians and mental health experts created the diagnoses AN and BN, which were viewed as a mental illnesses; and after the 1970s to 1980s, when the DSM classified the two diseases, respectively, as “eating disorders,” a category of mental illness associated with disturbances in body image of the patient.

Accounts of disordered eating behaviors according to current qualifications exist as early as 450-350 BCE, when doctors often suggested use of purging as a medical treatment. This idea stemmed from the common belief during that time period in the Humoral Theory, which stated that the four humors of the body had to be in balance in order for an individual to lead a healthy life free of illness. In a text on “Ancient Medicine” that the Greek physician Hippocrates, who is generally credited with initiating this theory, wrote in 400 BCE, he suggested use of purging to clear “overflow of the bitter principle, which we call yellow bile.”5 During this time period, far from there being a link of purging behaviors to body image, there was not even a notion that self-induced purging could be a disease itself. It was, instead, a treatment.

The possibility that purging could indicate disease is also nonexistent in other historical accounts of individuals who exhibit behaviors that would match more closely bulimic diagnostic criteria today. In his biographical book The Lives of The Twelve Caesars, the Roman historian Suetonius, in 121 CE, describes the binging and purging tendencies of Emperors Claudius and Vitellius. According to Suetonius, Emperor Claudius would “thoroughly cram[] himself” with food,” after which a “feather was put down his throat, to make him throw up the contents of his stomach,” while Emperor Vitellius would “always [eat] three meals a day, sometimes four” that he followed up with a “custom” of “frequently vomiting.”6 When describing both emperors, Suetonius does not focus on the disordered eating behaviors themselves. Instead, he emphasizes their general indulgence by saying they are “chiefly addicted to the vices of luxury and cruelty,” which he views with disapproval.7 There seemed to be an association during this time period of binging and purging with the wealthy, who were likely the only ones who could afford to engage in such eating behaviors. While the eating patterns of the emperors could satisfy criteria of bulimia diagnosis today, the cultural meaning— or “thick description,” as the renowned American cultural anthropologist Geertz would call it—surrounding purposeful binging and purging in that time period was entirely different, which led to an assumption that they were not a disease but a status symbol representing the rich.8

Similar to binging and purging, self-induced starvation had an ascribed cultural meaning distinct from that in its association with anorexia today. While self-induced starvation in modern anorexic patients is associated with poor body image, many historical cases of this disordered eating behavior, for instance, were linked to religion. The Catholic lady Saint Catherine Benincasa of Siena (1347-80) has been the subject of great debate in modern discussions of AN for her extreme religious fasting. Although Benincasa displayed symptoms of the disease in her refusal to eat and significant weight loss, her letters show that her reasons for starvation were to encourage self-discipline and moderation, which she believed would help her soul become closer to God: “there is more perfection in renunciation than in possession…. he [man] ought to renounce and abandon [his ‘riches’] with holy desire, and not to place his chief affections upon them, but upon God alone.”9 Benincasa even discouraged her friend whose fasting had caused her to become excessively skinny—a body that many anorexic patients would crave for—from continuing to fast, because she has now lost the self-discipline that she was trying to attain through fasting.

While some of the eating behaviors of Benincasa and her friend fit current qualifications for AN, neither of them had the disease because the cultural meaning ascribed to starvation then was different, which is likely one reason the diagnosis of anorexia did not exist and, consequently, cannot be applied to her. The case of the “Welsh-fasting girl” Sarah Jacobs (1857-1869), who claimed to survive without food or water for two years, marks another key historical case in which starvation was linked to religion. Dr. Robert Fowler, a physician closely involved in monitoring and treating Jacobs, described her as “very much devoted to religious reading” since youth, which was likely the reason she began her façade of fasting: to convince the public of her divine status.10 Amazed by her capability to survive without food, “hundreds” of “people came from all parts of the country to see Sarah,” leaving her with gifts from books and clothes to large sums of money.11 Even the parents of Jacobs became convinced that “she was supernatural” and “would not… die like the[ir] other children” because “the Lord would provide for her in a supernatural way.”12

However, emerging skepticism within the medical community led doctors to conduct a test in which nurses monitored the home of Jacobs to ensure she was not consuming food covertly. During this period, Jacobs became extremely thin and began having convulsions, indicating she was clearly malnourished, but she continuously declined food. Although she exhibited disordered eating behaviors to the public in her refusal of food during her feigned and actual starvation, those behaviors were not labeled a disease. Instead, the secondary symptoms she experienced after excessive weight loss led doctors to diagnose her with other diseases such as hyperaesthesia, hysteria hysterical epilepsy, and aphagia. Jacobs was one among many other Victorian girls who made similar claims to surviving without food, though the case of Jacobs is most famous because she was the only one who resisted intake of food until her death by starvation.

In addition to the fact that EDs were not a disease during the era Jacobs lived, the view of a good body seemed to differ during that time. In the DSM-V, one of the three major criteria used to diagnose an individual with AN, besides a general disturbance in body image, is an “Intense fear of gaining weight or of becoming fat.”13 While individuals with AN today starve themselves because they consider a thinner body to be more beautiful, an 1869 article written in the British Medical Journal a few days after the death of Jacobs, describes how Jacobs, “In appearance… was decidedly pretty” prior to her starved state for “having a plump, ruddy face.”14 While the current DSM-V assumes that the desire of a patient to be skinny causes AN, this supposition is entirely absent from many past accounts of self-induced starvation, such as that of Benincasa and the Welsh fasting girl, an indication that definitions surrounding disordered eating behaviors are culturally grounded. Even a comparison of Benincasa of the 1300s to Jacobs of the 1800s shows disparities in the meaning ascribed to the refusal of food across two periods where EDs did not exist: Benincasa, amongst others in her time period, starved herself to attain salvation from God on a personal level, while Jacobs, amongst many other Victorian girls in her time period, pretended to starve herself in order to give off an appearance of being divine. The period between when Benincasa and Jacobs lived contains what are now considered to be the first medical descriptions of AN. In his 1694 book Phthisiologia, or, A Treatise of Consumptions detailing the causes, symptoms, and treatments for diseases of “consumption,” the physician Richard Morton discusses seeing two unique cases for the first time: a girl who suffered from a reduced appetite and “a Skeleton [body] clad only with skin” but without any typical fevers or coughs accompanying those symptoms, and a 16-year-old boy who suffered from significant weight loss.15

For both patients, however, Morton credited the starved state to “nervous,” or emotional, causes, naming the disease causing their conditions “Nervous Atrophy, or Confumption.”16 In the case of the latter, he attributed the weight loss specifically to “ftu-dying [studying] too hard, and the Paffions of his Mind,” and consequently, “advis’d him” as treatment “to abandon his Studies, to go into the Country Air, and to ufe Riding, and a Milk Diet… for a long time.”17 The etiology that Morton gave and the treatments he prescribed for the inexplicable self-induced weight loss in the two patients suggests that physicians like him in that time period considered weight loss to be only a secondary symptom of a different disease. The possibility of purposeful self-induced starvation for weight loss, once again, did not seem to exist in that time. This assumption would continue well throughout the twentieth century, beginning with Sir. William Gull himself. The coining of AN as a diagnosis by Sir William Withey Gull, MD, occurred only a few years after the death of Sarah Jacobs in December of 1869. In the paper he presented on “anorexia nervosa” in an address on October 24, 1873, he defined the condition as a “peculiar form of disease occurring mostly in young women… chiefly between the ages of 16 and 23” that is “characterised by extreme emaciation, and often referred to latent tubercle, and mesenteric disease.”18 Though he initially called the disease “Apepsia Hysteria,” he changed the name to anorexia nervosa in this paper because “Anorexia,” or loss of appetite in Greek, “would be more correct,” and “nervosa” avoids confusion of the disease with hysteria.19 Of utmost significance in this paper is his attribution of the etiology of the disease to “a morbid mental state” that “destroy[s] the appetite of the patient.”20 In doing so, Gull does not consider either the desire of the patient for weight loss or the idea of a poor body image of the patient as an etiology of the disease in his ensuing discussion of three female patients he treated who suffered from “anorexia nervosa.” This assumption could perhaps be attributed to the view of a good-looking body during that time as being “plump,” the word used to describe the face of Sarah Jacobs when she was “decidedly pretty” before starving herself.21

Overall, the cultural context surrounding distorted eating patterns, such as self-induced starvation, was different in the late 1800s than it is now, when EDs serve as a symbol of distorted body image. The question, then, of whether the starved women that Gull indeed had AN—a disease diagnosed today based upon a disturbance in body image of the patient causing self-induced starvation for intentional weight loss—is debatable. What is clear, however, is that the cases Gull saw, and AN as a diagnosis itself, were not EDs, a categorization that did not exist in that time. The assumption that AN, following its creation as a diagnosis, was solely a mental illness, with no special category of ED linking it to body image, is evident in other articles written later in the early 1900s. The physician Henry B. Richardson, for instance, diagnosed six patients in 1939 who suffered extreme emaciation with no known physical causes as having AN because, “Anorexia nervosa is diagnosed by the demonstration of the neurosis.” Many medical professionals searched for psychosomatic explanations for the refusal of food by patients with AN. In a 1937 paper called “Dreams in so-called endogenic magersucht (anorexia),” German physician ViktorVon Weizsäcker analyzed the dreams of patients during a restriction phase associated with AN and following periodic binges that he descriptively described as “bulimia,” meaning excess appetite. He diagnosed the patients with only AN, though, since “bulimia nervosa” was not a disease then. Ultimately, he found themes of “disembodiment… and “death” in the dreams of the patients immediately following their food restriction and binging, and he concluded from his investigation that their refusal of food was due to a “longing for death.”22 The Canadian psychoanalyst W. Clifford M. Scott attributed the lack of appetite in young anorexic patients to “complex emotional problems,” such as “earliest anxiety situations of a paranoid type” and, in older women, to sexual mishaps earlier in life.23 Neither of the physicians alluded to a desired weight loss of the patient or distorted body image as a cause when searching for an etiology associated with anorexia nervosa.

The evolution of self-induced starvation, binging and purging from exclusively mental illnesses to, more specifically, EDs, a type of mental illness inextricably linked to body image, is evident in the evolution of the DSM criteria of the diseases. In the first version of the DSM (1952), the terms “anorexia” and “bulimia” were listed as digestive symptoms meaning “loss of appetite” and “excessive appetite,” respectively.24 The DSM-II (1968) qualified AN as a diagnosis of a “Feeding Disturbance” under a section called “Special Symptoms,” but it did not designate the disease as an ED linked to body image.25 The DSM-III (1980) was the first version in which both “anorexia nervosa” and “bulimia” appeared as illnesses under the designation ED, and it was also the first time that the diagnostic criteria of AN includes a “Disturbance of body image.”26 The diagnosis of “bulimia” still did not have this association with body image in that DSM-III, but, only seven years later, a revised version called the DSM-III-R altered the diagnosis “bulimia” to “bulimia nervosa” that was coupled with an addition of “Persistent over-concern with body shape and weight’ as one of the four diagnostic criteria for the disease.27 The DSM-III-R marked a critical turning point after which both AN and BN were, henceforth, qualified as EDs, a mental illness linked diagnostically to body image.

A simple sampling of articles ranging from the 1970s to 1980s, the approximate period when disordered eating behaviors shifted from solely mental illnesses to a special category of mental illnesses called EDs, to today shows how closely EDs were and continue to be linked to body image. In a newspaper article written in 1987, Vicky Cosstick, a facilitator of NGOs that focus on combating global issues from poverty to EDs, discusses the case of her friend, Judy, who she called a “typical anorexic” in that her “refusal to eat” arose out of a desire to “impress others” based on “her perceptions [that] their expectations of her” were to be skinny.28 According to Cosstick, Judy would “describe[e] other, normal women as revoltingly fat (including [Cosstick]).”29

The distorted body image that causes many ED patients, such as Judy, to engage in anorexic and bulimic behaviors today stems from a modern-day cultural assumption that a thin body is the ideal and, in some cases, the standard of beauty. A survey conducted in 2003 on 131 female beauty pageant contestants indicated that about half (48.5%) wanted to be thinner and 57% were attempting to lose weight. Furthermore, when provided a scale from 1-7 containing images of women with increasing body sizes, the contestants, on average, ranked their “current body size” the highest (3.75), followed by the “ideal size for a woman” (3.31) and the “perception of [the] size [a] pageant judge would select as a beauty queen” (2.63).30 Not only did the contestants themselves believe that the ideal body for a woman was thinner than their own, but they also believed that the public felt the same.

This cultural assumption is, furthermore, visible in a famous poem called “Ellen West” that Frank Bidart, a Pulitzer-prize winning American poet, wrote in 1990 based on a case account by the psychiatrist who treated Ellen West, a pseudonym for a woman (1888-1921) who suffered from anorexia, bulimia, and possibly other psychotic illnesses that led her to commit suicide at age 33. Written from the perspective of Ellen West, the poem describes the tension West feels between her cravings for food and her desire to remain thin, which she views as “ideal,” and her desire to “defeat [the] ‘Nature’” that makes her gain weight.31 While the poem does accurately describe some facts in the case history and the feelings of Ellen West, it also incorporates Bidart’s interpretation of what he considered the beliefs of West. Ellen West clearly had a fear of becoming fat and a desire to have a thinner body, as she herself stated, “If there were a substance which contained nourishment in the most concentrated form and on which I would remain thin, then I would still be so glad to continue living.”32 Bidart, nonetheless, assumes in this poem that part of her desire to be thin stems from the view of West that skinniness is “beautiful.”33

In one part of the poem, West describes that when she sees a woman “with sharp, clear features, a good bone structure” indicating she is thin, “She was beautiful.”34 While both Bidart and Ellen West considered a thin body to be the ideal, Bidart assumes that West believed thinness is associated with beauty, which he projects on Ellen West in his poem. Overall, a historical analysis of disordered eating patterns from before the first century until now shows how greatly the cultural connotations of those behaviors change across time periods. A single behavior, whether it be binging, purging, or starvation, received approval based on its association with concepts ranging from indulgence and religion to mental illnesses associated with body image.

At no time in before the 1900s was an etiological link even suggested between the three behaviors of starvation, binging, and purging and body image, the basis upon which they are grouped together as EDs today. The cultural context that led to the creation of EDs as a diagnosis was absent from the past, which led to an assumption during and before the 1900s that self-induced starvation, binging, and purging for purposeful weight loss did not exist. For this reason, the diagnoses EDs cannot be ascribed to patients in the past who exhibited disordered eating patterns. In the words of Harvard medical historian Charles Rosenberg, “Even those contemporary Western notions of disease specificity that seem to most of us somehow right and inevitable… are… socially constructed, like everything else in our culture.”35 Observing the evolution of anorexia and bulimia in the DSM itself reveals the cultural bias of the criteria for the diagnosis of EDs in its association with poor body image. The shift of starvation, binging, and purging from emblematic eating behaviors to “eating disorders” may lead us to reflect on our own cultural beliefs today and ask why, unlike in the past, we choose to make sense of these behaviors by labeling them a "disease."

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Endnotes

1.) Eating disorder statistics. (2017). Retrieved from http://www.anad.org/education-and-awareness/about-eating-disorders/eating-disorders-statistics/

2.) Janet Golden contends a related idea about Fetal Alcohol Syndrome in her 2005 book Message in a Bottle: The Making of Fetal Alcohol Syndrome.

3.) Plotkin, M. (2016, March 14). A brief history of eating disorders & binge eating disorder. Retrieved from https://bedaonline.com/a-brief-history-of-eating-disorders-binge-eating-disorder/

4.) American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.

5.) Hippocrates. (450-400 B.C.E). On Ancient Medicine (F. Adams, Trans.). Retrieved from http://classics.mit.edu/Hippocrates/ancimed.mb.txt

6.) Tranquillus, G. S. (121 C.E). The Lives of the Twelve Caesars (T. Forester, Ed.; A. Thomas, Trans.). Retrieved from http://www.gutenberg.org/files/6400/6400-h/6400-h.htm#link2H_4_0006

7.) Tranquillus, G. S. (121 C.E.). The Lives of the Twelve Caesars (T. Forester, Ed.; A. Thomas, Trans.). Retrieved from http://www.gutenberg.org/files/6400/6400-h/6400-h.htm#link2H_4_0006

8.) Geertz, C. (1973). Thick Description: Toward an Interpretive Theory of Culture. The Interpretation of Cultures: Selected Essays (pp. 3–30). Basic Books.

9.) Benincasa, C. (2005, February). Letters of Catherine Benincasa (V. D. Scudder, Ed.; V. D. Scudder, Trans.). Retrieved from http://www.gutenberg.org/cache/epub/7403/pg7403-images.html

10.) Fowler, R. (1871).A complete history of the case of the Welsh fasting-girl (Sarah Jacob). Retrieved from archive.org/stream/b23982706#page/8/mode/2up

11.) Fowler, R. (1871).A complete history of the case of the Welsh fasting-girl (Sarah Jacob). Retrieved from archive.org/stream/b23982706#page/8/mode/2up

12.) Fowler, R. (1871).A complete history of the case of the Welsh fasting-girl (Sarah Jacob). Retrieved from archive.org/stream/b23982706#page/8/mode/2up

13.) American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

14.) The Welsh Fasting Girl. (1869).The British Medical Journal,2(469), 685-688. Retrieved from http://www.jstor.org/stable/25218005

15.) Morton, R. (1694).Phthisiologia, or, A Treatise of Consumptions. Retrieved from archive.org/stream/phthisiologiaort00mort#page/21/mode/2up

16.) Morton, R. (1694).Phthisiologia, or, A Treatise of Consumptions. Retrieved from archive.org/stream/phthisiologiaort00mort#page/21/mode/2up

17.) Morton, R. (1694).Phthisiologia, or, A Treatise of Consumptions. Retrieved from archive.org/stream/phthisiologiaort00mort#page/21/mode/2up

18.) Gull, W. W. (1997). V.-Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica).Obesity Research,5(5), 498-502. doi:10.1002/j.1550-8528.1997.tb00677.x

19.) Gull, W. W. (1997). V.-Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica).Obesity Research,5(5), 498-502. doi:10.1002/j.1550-8528.1997.tb00677.x

20.) Gull, W. W. (1997). V.-Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica).Obesity Research,5(5), 498-502. doi:10.1002/j.1550-8528.1997.tb00677.x

21.) The Welsh Fasting Girl. (1869).The British Medical Journal,2(469), 685-688. Retrieved from http://www.jstor.org/stable/25218005

22.) Jackson, C. , Beumont, P. J., Thornton, C. and Lennerts, W. (1993), Dreams of death: Von Weizsäcker's dreams in so‐called endogenic anorexia: A research note. International Journal of Eating Disorders, 13: 329-332. doi:10.1002/1098-108X(199304)13:3<329::AID-EAT2260130312>3.0.CO;2-R

23.) Scott, W. M. (1948). Notes on the psychopathology of anorexia nervosa*.British Journal of Medical Psychology,21(4), 241-247. doi:10.1111/j.2044-8341.1948.tb01174.x

24.) American Psychiatric Association. (1952). Diagnostic and statistical manual of mental disorders (1st ed.). Washington, DC: American Psychiatric Publishing.

25.) American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.). Washington, DC: American Psychiatric Publishing.

26.) American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: American Psychiatric Publishing.

27.) American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3-R ed.). Washington, DC: American Psychiatric Publishing.

28.) Cosstick, V. (Summer 1978). Anorexia Nervosa. New Directions for Women, p. 9. Gale. Retrieved from http://tinyurl.galegroup.com/tinyurl/5K7721

29.) Cosstick, V. (Summer 1978). Anorexia Nervosa. New Directions for Women, p. 9. Gale. Retrieved from http://tinyurl.galegroup.com/tinyurl/5K7721

30.) Thompson, S. H., & Hammond, K. (2003). Beauty is as beauty does: Body image and self-esteem of pageant contestants.Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity,8(3), 231-237. doi:10.1007/bf03325019

31.) Bidart, F. (1990). Ellen West. Retrieved from https://www.poetryfoundation.org/poems/48284/ellen-west

32.) May, R., Angel, E., & Ellenberger, H. F. (2004).Existence. Lanham, MD: Rowman & Littlefield.

33.) Bidart, F. (1990). Ellen West. Retrieved from https://www.poetryfoundation.org/poems/48284/ellen-west

34.) Bidart, F. (1990). Ellen West. Retrieved from https://www.poetryfoundation.org/poems/48284/ellen-west

35.) Rosenberg, C. E. (2003). What is disease?: In memory of Owsei Temkin.Bulletin of the History of Medicine,77(3), 491-505. doi:10.1353/bhm.2003.0139