Anorexia Nervosa

by

Karin Eli, Stanley Ulijaszek

• LAST REVIEWED: 23 April 2021
• LAST MODIFIED: 23 March 2023
• DOI: 10.1093/obo/9780199766567-0116

Introduction

With its multidimensional etiology, rich history, and increasingly complex epidemiology, anorexia nervosa (from here on, referred to as “anorexia”) has emerged as a biocultural disorder of significance for medical anthropology. Anthropological work on anorexia was first published in the 1980s, with these initial engagements examining the Western cultural context wherein anorexia was known to be expressed. Over the decades, paradigm shifts in medical anthropology—from culture-bound syndromes and explanatory models of disease to analyses of globalization and ethnographies of the body and self—transitioned the anthropological discussion of anorexia away from “culture” and toward the critical analysis of practice, experience, and subjectivity. But the anthropological narrative of anorexia is even richer, having been informed by more than a century of multidisciplinary work: a vast corpus that constitutes an unlikely gathering of disciplines, all searching for the key to anorexia’s causation and course. Since its clinical definition in the 1870s, anorexia—a disorder of ambiguous and complex causation, with striking psychological, social, physiological, and behavioral manifestations—has been subject to myriad interpretations. In fields ranging from biomedical (including genetic and neuro-) science to the many schools of psychology, history, and feminist social theory, scholars have offered interpretations of anorexia, each addressing a facet of this condition. With historical analyses tracing anorexia through the 1800s and to pre-Enlightenment times, feminist analyses positioning anorexia as the embodiment of sociopolitical thought, and evolutionary and genetic analyses suggesting anorexia is the possible expression of adaptive traits, multidisciplinary work on anorexia has captured a complexity that is yet to be fully understood. It is this complexity, blurring the boundaries of body, society, history, and self, that makes anorexia so relevant for medical anthropology, its enduring ambiguities evoking the wholeness of the human experience that anthropological research seeks to explain. Given the nature of the anorexia literature on which anthropological research draws, this article does not highlight genres of publication: journals and textbooks dedicated to eating disorders tend to be exclusively clinical, emphasizing biomedical research and quantitative data analyses (rather than clinical case reports), such that they would not provide the most-salient references for anthropologists. The works featured in this article are divided, therefore, according to the analytic perspectives they express. Emphasis is placed on the history of thought on anorexia, while drawing out the salience of specific works for contemporary anthropological research.

Foundational Clinical Accounts

A defined clinical entity since the 1870s (Lasègue 1873, Gull 1874), anorexia nervosa was subject to the paradigm shifts that defined psychiatry and psychosomatic medicine in the century that followed (see Brumberg 1988, cited under Historical Perspectives). While several notable papers on anorexia (including the analysis of anorexic body image in Bruch 1962) were published in the 1960s, the period of the 1970s was a defining one for clinical scholarship on this phenomenon, seeing the publication of several influential works that still impact contemporary debates. Russell 1979, the first article to distinguish bulimia from anorexia definitively, has significantly shaped the clinical definition and understanding of these disorders and continues to inform the current clinical definition of bulimia nervosa. Bruch 1978, The Golden Cage, which drew on conversations with the author’s anorexic patients, is often credited with bringing anorexia out of the clinical realm and into public consciousness, and it is a central reference work for contemporary scholars. Furthermore, Bruch 1978, which links anorexia and the assertion of control, and Crisp 1980, which casts anorexia as an adolescent reversal of maturation, continue to influence popular understandings of anorexic psychology. Notably, while these works have significantly influenced the field, they have not inspired consensus: Minuchin, et al.’s model (Minuchin, et al. 1978) of the “pathological” anorexic family system has proven particularly controversial, having been contested both by feminist scholars and by clinical and lay supporters of the Maudsley (family-based treatment) approach.

• Bruch, Hilde. 1962. Perceptual and conceptual disturbances in anorexia nervosa. Psychosomatic Medicine 24.2: 187–194.

  DOI: 10.1097/00006842-196203000-00009

  Based on the clinical cases of twelve patients, Bruch argues that anorexia nervosa entails a distortion in body image perception and detachment from the sensory realities of the body, such that anorexic people do not grasp their own wasting, weakness, and hunger. She suggests that these distortions link with the anorexic person’s pervasive “sense of ineffectiveness” and reactivity within the family. Available online for purchase or by subscription.

• Bruch, Hilde. 1978. The golden cage: The enigma of anorexia nervosa. Cambridge, MA: Harvard Univ. Press.

  Directed at a lay audience, Bruch’s monograph brought anorexia nervosa into broad public consciousness. Bruch links anorexia nervosa to individuation in adolescence, arguing that for young women compelled into compliance with parental (and societal) expectations, anorexia provides a means of asserting control, power, and uniqueness through extreme practice. She breaks with psychoanalytic approaches, asserting that therapy should emphasize the anorexic woman’s self-expression rather than impose interpretations.

• Crisp, Arthur Hamilton. 1980. Anorexia nervosa: Let me be. London: Academic Press.

  Crisp argues that anorexia, rather than expressing symbolic concerns (as in the psychoanalytic view), is an adaptive disorder, used by vulnerable adolescents to avoid the psychosocial stresses of puberty and maturation. He suggests that starvation is significant in affecting the body’s shape and weight, allowing it to regress to prepubertal proportions and reverse sexual maturation, thereby enabling the anorexic adolescent not to develop an adult social and sexual life.

• Gull, William Withey. 1874. Anorexia nervosa (apepsia hysterica, anorexia hysterica). Transactions of the Clinical Society of London 7:22–28.

  Gull describes the cases of two young women whom he diagnosed as anorexic, explicating the diagnosis as one that precludes physiological causation and relies on psychogenic origins. His case descriptions include the physical and behavioral manifestations of the disorder, as well as treatment and its outcomes. The article is notable for coining the term “anorexia nervosa.”

• Lasègue, Charles. 1873. On hysterical anorexia. Medical Times and Gazette, 6 September, 265–266.

  Continued in Medical Times and Gazette, 27 September 1873, 367–369. Lasègue’s two-part analysis of his young female patients’ anorexia identifies adverse maturational events (such as romantic disappointments or emotional upheavals) as the root of the disorder. While Lasègue positions anorexia within the realm of hysteria, reflecting the psychiatric nosology of the time, the article is remarkable in its early, keen delineation of family food dynamics that contribute to, and perpetuate, anorexic practice.

• Minuchin, Salvador, Bernice L. Rosman, and Lester Baker. 1978. Psychosomatic families: Anorexia nervosa in context. Cambridge, MA: Harvard Univ. Press.

  DOI: 10.4159/harvard.9780674418233

  Minuchin, Rosman, and Baker analyze anorexia as a disorder of family systems, arguing that adolescents develop anorexia through feedback loops of interactions between immediate family members, such that anorexic practice both regulates and is regulated by household dynamics. They describe the anorexic family as enmeshed, where the adolescent internalizes parental scrutiny and expectations, developing anorexia to maintain vigilance over herself and alliance with her parents.

• Russell, Gerald. 1979. Bulimia nervosa: An ominous variant of anorexia nervosa. Psychological Medicine 9.3: 429–448.

  DOI: 10.1017/S0033291700031974

  Russell’s article definitively introduced bulimia nervosa as a distinct clinical entity. Analyzing the case histories of thirty patients, Russell offers a detailed clinical account of bulimia nervosa, including psychological, physiological, and behavioral aspects. He argues that while anorexic and bulimic people have similar attitudes toward body size, bulimia nervosa is characterized by overwhelming “urges to overeat” and can manifest in the absence of amenorrhea and emaciation. Available online for purchase or by subscription.