As defined by the American Psychiatric Association's Diagnostic and Statistical Manual, fourth edition (DSM-IV;1994), anorexia nervosa is an eating disorder marked by four major symptoms. First, the patient must be less than 85 percent of ideal weight for age, height, and gender. Second, there must be a morbid fear of fat. Third, the person must believe himself or herself to be normal weight or even fat despite emaciation. Finally, the victim should be amenorrheic (i.e., have no menstrual periods) or, in the case of men, show abnormally low levels of testosterone. Anorexia nervosa is considerably more common in women than in men with 80 to 90 percent of the cases diagnosed in adolescence or adulthood being females. The gender difference is somewhat less pronounced in childhood cases, with girls being approximately five times more likely than boys to suffer from the disorder. Less than 1 percent of the postpubertal female population suffers from anorexia nervosa. It is more common among white than African-American girls and women.
Anorexia nervosa has two ages of peak onset: around age fourteen, and at about age eighteen. The frequency of adolescent onset has led theorists to suggest that the developmental transitions to ADOLESCENCE and to adulthood present special risks for girls, making them more vulnerable than boys are not only to anorexia nervosa but also bulimia nervosa and depression. The combination of age and gender factors has also led theorists to suggest that cultural variables, such as the thin body ideal for females and the relative lack of power among women, contributes to the disorder. Finally, it is clear that anorexia nervosa typically starts in a pattern of either dieting or excessive exercise which itself is probably rooted in an attempt to achieve a particular body shape.
There are at least two paths that lead to the modern definition of anorexia nervosa. The first is self-starvation. The second is a history of defining adolescence and young adulthood as problematic for women. These historical trends meet in the eighteenth century to define anorexia nervosa.
Walter Vandereycken and Ron van Deth (1994) suggest that self-starvation is a pervasive phenomenon in human history. Given the cross-cultural and cross-historical presence of self-starvation, it is not surprising that it has many motivations. Perhaps the best-known motives are political and religious. For example, Mahatma Gandhi's lengthy hunger strikes in defiance of British domination of India in the 1930s are well known. Less dramatically, fasting is required of Roman Catholics on certain holy days during Lent and even today, devout Muslims participate in a month-long fast during Ramadan.
The link between religion and self-starvation has received the most attention from students of anorexia nervosa. The link between self-denial, including of food, and spirituality, dates at least as far back as the Egyptian pharaohs. During the fourth and fifth centuries C.E., men went into the Egyptian and Palestinian deserts to dedicate themselves to the worship of Jesus Christ. Self-starvation was part of this dedication. As religious practice was largely limited to men at this time, most of those engaging in religious selfstarvation were men.
Of greater interest in terms of anorexia nervosa is the medieval practice of self-starvation by women, including some young women, in the name of religious piety and purity. By the twelfth century, it was increasingly common for women to participate in religious life and to even be named as saints by the Catholic Church. Many women who ultimatimately became saints engaged in self-starvation, including St. Hedwig of Silesia in the thirteenth century and Catherine of Siena in the fourteenth century. By the time of Catherine of Siena, however, the Church became concerned about extreme fasting as an indicator of spirituality and a path to sainthood. Indeed, Catherine of Siena was told to pray that she would be able to eat again, but was unable to give up fasting.
While there is a long-standing link between self-starvation and piety, there is also a historical relationship between self-starvation and demonic possession or witchcraft. For example, Catherine of Siena ate something everyday so that she would not be labeled a witch. After the middle ages, numerous "fasting saints" were accused of witchcraft under the Inquisition. In some places, women could prove they were not witches if they weighed a sufficient amount on government-designated scales. Again, the relationship between self-starvation and religion was particularly pronounced for women.
The virtually simultaneous designation of self-starvation by women as pious and demonic raises interesting issues concerning the cultural meaning of women's bodies, issues that are still debated in terms of anorexia nervosa. In the calculus of the early twenty-first century, the ideal body type for women is thin. "Supermodels," actresses, and even singers are typically substantially below the weight of the average American woman. Research indicates that this image is so pervasive that even elementary school-age children are aware of it. Studies routinely find that 40 percent of girls in fourth and fifth grade wish they were thinner or worry about getting fat. Yet, if girls take this message too much to heart, dieting severely and actually becoming as thin as the models, they are considered "mentally ill."
Anorexia nervosa is not the first disorder in history marked by unusual eating and amenorrhea that is found predominantly in adolescent or young adult women. According to Brett Silverstein and Deborah Perlick (1995), a paper by Hippocrates, known as On the Disease of Young Women, describes an anorexia nervosa-like disorder. This treatise suggests that the dramatic weight loss is caused by problematic menstrual cycles and recommends marriage and pregnancy as the best treatment.
Similarly, hysteria, a disorder made famous in SIGMUND FREUD's Anna O. case but that was also diagnosed earlier in the nineteenth century, was marked by loss of appetite, depression, and amenorrhea. Neurasthenia was another late nineteenth century "female disorder" involving disordered eating and amenorrhea.
Probably the best known of these disorders of adolescent girls is chlorosis. Chlorosis was made famous by Joan Jacob Brumberg's book Fasting Girls. Brumberg argues that chlorosis, like anorexia nervosa, was a disease of middle-class American girls who were fulfilling the expectations of their culture in an extreme manner. In both the nineteenth and twentieth centuries, such girls developed exaggerated behaviors concerning food. Chlorosis was a form of anemia, found only in girls, that was linked to both the onset of menstruation and physical attractiveness. Oddly, these ill girls were considered particularly attractive, just as the most "beautiful" women in the United States of the early twenty-first century have an anorexic appearance. Chlorotic girls, like those with anorexia nervosa, were likely trying to exercise some control over their own lives and, like anorexic girls, were considered to be suffering from a "nervous" or "psychological" disorder rather than from a primarily physical illness.
By the early twentieth century, chlorosis was no longer being diagnosed in the United States. While it is possible that improved nutrition led to the decline of this form of anemia, it is more likely that culture changes affected the expression of eating-related pathology among adolescent girls. The belief that women were fragile and physically weak generally declined as opportunities for women in jobs, education, and even politics increased. However these changes were not quickly or universally accepted, setting up a clash between images of the "traditional" and the "modern" young woman. Young girls received and internalized these conflicting messages about womanhood and may have sometimes felt unable to control their own destinies or to even know want they wanted to do. One thing they could control, however, was their own eating. This culture-based model resonates with current explanations of the causes of anorexia nervosa.
Neither the "fasting saints" nor the "chlorotic girls" were anorexic in the sense that the term is used today. Their self-starvation and "nervous" illness reflected beliefs and women's roles during their historic periods. Although Richard Morton described a case of tuberculosis that resembled anorexia nervosa in 1694, current definitions of the disorder are routinely traced to the work of Sir William Withey Gull and Dr. R. Lasègue, in 1874 and 1873 respectively.
Both Lasègue and Gull describe cases marked by self-starvation and high levels of activity or restlessness. Both note that the problem is particularly pronounced in young women; indeed, Gull suggests that adolescent and young adult women are unusually susceptible to MENTAL ILLNESS. Lasègue notes that these young women are pleased with their food restriction, do not wish to eat more, and do not believe that they are abnormally thin. Lasègue referred to this condition as hysterical anorexia while Gull used the term anorexia nervosa.
Although Gull and Lasègue considered anorexia to be a "nervous" disorder, both treated it medically. Gull in particular seemed to have remarkable success, at least by today's standards, in gradually re-feeding the girls. He reported that his clients recovered their eating habits, weight, and health. Lasègue had more pessimistic reports, noting that patients often went many years without recovering.
It is important to recognize that neither Gull nor Lasègue considered anything resembling a "drive for thinness" as key in the etiology of anorexia nervosa. This focus is a product of the twentieth century, probably instigated by the work of Hilde Bruch. Some practitioners are now questioning the wisdom of the twentieth and twenty-first century emphasis on the role of drive for thinness in anorexia nervosa. They note that in some Asian cultures, particularly Hong Kong and China, drive for thinness does not seem to be part of what otherwise looks like anorexia nervosa. Others note that Gull's success in using medically based treatments ought to encourage us to re-examine the efficacy of such an approach.
Historians have raised a number of issues concerning the emergence of modern anorexia nervosa, which was a trans-Atlantic phenomenon involving both the United States and Western Europe from the mid-nineteenth century onward. The basic issues involve sorting out the "real" disease from its specific historical cause–why the disease emerged when it did– and the fact that it appears so disproportionately in females. The first outcroppings of the modern disease occurred before thinness was widely fashionable, which has prompted consideration of the dynamic of loving, middle-class families in which some young women chose food refusal as a method of rebellion that could not be explicitly articulated. Obviously, the rise of concern for slenderness from about 1900 onward as a fashion standard particularly bearing on women, helped sustain the disease. But the incidence of anorexia was not constant through the twentieth century in the Western world, raising questions about causation and about fluctuations in medical attention. By the 1970s, societal and parental concern about anorexia was widespread, sometimes working against efforts to limit children's food intake in a period when the incidence of childhood obesity was rising more rapidly than anorexia nervosa.
In its current form, anorexia nervosa dates from the midnineteenth century. Yet, it grows out of a long history of self-starvation and female-specific pathologies. As such, it likely is a disorder that can tell us much about the role of young women in today's society and why they opt to wage war against their own bodies.
Andersen, Arnold E. 1985. Practical Comprehensive Treatment of Anorexia Nervosa and Bulimia. Baltimore, MD: The Johns Hopkins University Press.
Brumberg, Joan Jacobs. 1982. "Chlorotic Girls, 1870-1910: An Historical Perspective on Female Adolescence." Child Development 53: 1468-1474.
Brumberg, Joan Jacobs. 1988. Fasting Girls: The Emergence of Anorexia Nervosa. Cambridge, MA: Harvard University Press.
Silverstein, Brett and Deborah Perlick. 1995. The Cost of Competence: Why Inequality Causes Depression, Eating Disorders, and Illness in Women. New York: Oxford University Press.
Vandereycken, Walter and Ron van Deth. 1994. From Fasting Saints to Anorexic Girls: The History of Self-starvation. New York: New York University Press.
LINDA SMOLAK