Picture this: In our modern world, bombarded by images of ideal bodies and wellness trends, it's easy to assume that eating disorders are a relatively recent phenomenon, a byproduct of contemporary culture. We often associate them with the pressures of social media or the pursuit of an unattainable aesthetic.
However, the truth is far more complex and extends much further back in time. Evidence suggests that manifestations akin to what we now recognize as eating disorders have existed since antiquity, evolving in presentation and understanding across different eras. So, when did eating disorders truly begin to appear in human history, and how has our understanding of them changed?
This comprehensive guide delves into the fascinating and often challenging history of eating disorders, exploring their origins, their evolution from spiritual practices to clinical conditions, and when did eating disorders like anorexia nervosa, bulimia nervosa, and binge eating disorder gain formal recognition. Understanding this historical context is crucial for appreciating the depth and persistence of these complex conditions.
The Ancient Roots of Eating Disorders
While the term "eating disorder" is a modern construct, behaviors consistent with their symptoms have been documented for centuries. The earliest historical descriptions of individuals experiencing profound food deprivation or unusual eating patterns date back to Hellenistic times (323 BC-31 BC) and the medieval period (5th-15th century AD). During these eras, the denial of physical needs, including food, was often intertwined with profound spiritual or religious motivations.
Deprivation of food was frequently viewed as a path to spiritual purification or a demonstration of intense piety. For instance, historical accounts describe an upper-class twenty-year-old Roman girl who reportedly starved herself to death in pursuit of holiness (Witztum et al., 2008). Women, in particular, were disproportionately affected by extreme religious fasting, a phenomenon some contemporary scholars have termed "holy anorexia" (Hoskin et al., 2020).
The Middle Ages also yield numerous accounts of extreme self-induced fasting, often culminating in premature death due to starvation. A well-known example is St. Catherine of Siena, who died at 33 after reportedly practicing severe food abstinence as a form of religious devotion, eventually making it difficult for her to eat or even drink water (Sukkar et al., 2017). Similar ascetic practices were observed in other medieval mystics, such as Angela of Foligno or Mary of Oignies, whose extreme self-denial, while spiritually motivated, bore striking resemblances to modern food restriction (Witztum et al., 2008).
It's important to acknowledge that the primary motivation for this historical fasting differed significantly from the drive for thinness prevalent in modern discussions of eating disorders. Despite this distinction, many scholars believe these historical manifestations represent an early form of the same underlying disorder, simply taking on different meanings shaped by the prevailing sociocultural and religious climates.
Anorexia Nervosa: A Long and Evolving History
Early Descriptions and Naming
The question of when did eating disorders, specifically anorexia nervosa, first manifest in a way recognizable to modern medicine is often traced to the late 17th century. In 1689, English physician Richard Morton provided what are considered the earliest modern case descriptions of an illness strikingly similar to anorexia nervosa. He detailed cases in both a male and a female patient, noting a profound loss of appetite and physical wasting without an apparent physical cause, attributing it to a "Nervous Consumption" (Wilkinson, 2018).
Nearly two centuries later, in 1873, the term "anorexia nervosa" was officially coined by another English physician, Sir William Gull, in his published case reports. Concurrently, French physician Ernest Charles Lasegue published descriptions of individuals exhibiting "anorexie hysterique," further solidifying the recognition of this distinct condition (Valente, 2016). These parallel descriptions across different countries highlight a growing awareness of a specific syndrome.
Another compelling historical example is the case of Sarah Jacob, "the Welsh Fasting Girl," in the 19th century. Her prolonged refusal to eat garnered significant public and medical attention, reflecting an evolving understanding of conditions related to nervous debility and voluntary starvation, even amidst skepticism and controversy (Dell'Osso et al., 2016).
Modern Understanding and Diagnostic Advances
A pivotal moment in the modern understanding of anorexia nervosa occurred in 1982 with a foundational lecture by American doctor Hilde Bruch. Her work significantly influenced the conceptualization of the disorder, bringing it to wider public and medical awareness. However, more recent research has advanced beyond some of Dr. Bruch's earlier ideas, particularly those implicating early family dynamics as primary causes, which are now considered outdated (Treasure & Cardi, 2017).
Earlier psychoanalytic explanations of the illness have largely been superseded by a deeper understanding of genetic, biological, and socio-environmental processes. In 2003, researchers Keel and Klump proposed that the differing motivations for food refusal observed across various historical periods might simply represent culturally specific ways of understanding a core disorder that leaves individuals--disproportionately females--feeling unable and unwilling to eat (Keel & Klump, 2003).
Bulimia Nervosa: A More Recent Recognition
Ancient Behaviors vs. Modern Syndrome
In contrast to anorexia nervosa, which has discernible historical precedents, bulimia nervosa appears to be a more distinctly modern development. The debate around when did eating disorders like bulimia nervosa emerge often centers on distinguishing between ancient purging practices and the specific clinical syndrome.
While some historical accounts, such as those of ancient Roman emperors eating to excess and then vomiting, or the use of purging in ancient Egypt, Greece, Rome, and Arabia for disease prevention, describe behaviors reminiscent of bulimia, the motivations were fundamentally different. These ancient practices were often culturally sanctioned for specific purposes, not driven by a fear of fatness or body image concerns (Russell, 1979; Castillo & Weiselberg, 2017). For instance, Roman banquets sometimes featured emetics, not for disordered eating in the modern sense, but to allow guests to continue feasting, highlighting a cultural precedent for purging, even if the underlying psychological drivers were absent.
British psychiatrist Gerald Russell, who first described bulimia nervosa as a variant of anorexia in 1979, initially believed these ancient behaviors were culture-bound and not directly relevant to our modern understanding of the disorder (Russell, 1979). However, some contemporary researchers propose that these historical behaviors could represent early, albeit motivationally distinct, variants of bulimia nervosa, lacking the modern drive for thinness that defines the condition today.
Key Figures and Formal Recognition
Among the earliest cases that bear a clear resemblance to modern bulimia nervosa is that of Nadia, described by Pierre Janet in 1903. She exhibited a combination of dietary restriction, a profound fear of fatness, and episodes of binge eating, aligning closely with current diagnostic criteria (Gordon, 2015).
Another significant early description came from Mosche Wulff in 1932, detailing a patient who alternated between periods of fasting, overeating, and self-induced vomiting. In the 1960s, American psychiatrists Bliss and Branch published case histories that included several instances of bingeing and vomiting behaviors. German psychiatrist Ziolko further contributed in the 1970s, describing patients engaged in compulsive food intake and vomiting, coupled with heightened weight concerns (Gordon, 2015).
The formal recognition of bulimia nervosa came in 1979, when Gerald Russell published his seminal case series of 30 patients who reported self-induced vomiting to counteract the effects of overeating episodes. He determined that these cases represented a syndrome distinct from anorexia nervosa, yet shared the same underlying fear of fatness. His influential paper was titled "Bulimia nervosa: an ominous variant of anorexia nervosa" (Russell, 1979). Around the same time, in 1976, Christopher Fairburn also encountered an early case of bulimia nervosa, leading him to study the condition and develop pioneering treatments for it. The disorder, barely acknowledged before the latter half of the 20th century, has since become increasingly prevalent.
Binge Eating Disorder: From Concept to Clinical Diagnosis
Binge eating disorder (BED) arrived even later on the clinical scene. The disorder was first described in 1959 by psychiatrist Albert Stunkard, who initially coined the term "night eating syndrome." He later clarified that binge eating could occur independently of the nocturnal component of that particular syndrome (Stunkard, 1959).
Early studies of binge eating disorder primarily focused on weight loss populations, where the patterns of recurrent binge eating were frequently observed. These initial investigations laid the groundwork for distinguishing BED as a unique pattern of disordered eating.
A significant milestone occurred in 1993 with the publication of a cognitive behavioral therapy manual for binge eating and bulimia nervosa by Fairburn, Marcus, and Wilson. This manual detailed how cognitive behavioral therapy (CBT) could effectively treat both bulimia nervosa and binge eating disorder, quickly becoming the most widely studied manual for eating disorder treatment globally (Fairburn et al., 1993).
The journey of BED from an observed pattern to an independent diagnosis reflects a deepening understanding of eating pathology beyond restriction and purging, acknowledging the significant distress and impairment caused by recurrent episodes of eating large quantities of food without compensatory behaviors.
The Evolution of Eating Disorder Diagnoses
Understanding when did eating disorders become distinct diagnostic entities requires tracing their inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Anorexia nervosa, bulimia nervosa, and binge eating disorder entered this authoritative manual in a sequential order, reflecting evolving clinical understanding and consensus.
Anorexia Nervosa's Diagnostic Journey
Anorexia nervosa gained acceptance as a psychological disorder in the late 1800s following the influential reports of Morton, Gull, and Lasegue. Its formal inclusion in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) in 1952 marked it as the inaugural eating disorder to receive official psychiatric classification (Marks, 2019).
However, its initial categorization was as a "psychophysiologic gastrointestinal reaction," a broad umbrella term encompassing various gastrointestinal conditions like peptic ulcers or ulcerative colitis, where emotional factors were believed to play a causal role. The DSM-II, published in 1968, reclassified anorexia under "special symptoms," grouping it with other "special symptoms feeding disturbances" such as pica and rumination, indicating a gradual refinement in its understanding as a distinct feeding issue.
Bulimia Nervosa's Entry into the DSM
The DSM-III, released in 1980, represented a significant shift, as eating disorders debuted as their own diagnostic category, albeit under the rubric of "disorders of infancy, childhood, or adolescence." In this edition, "Bulimia" (not yet "Bulimia Nervosa") made its first appearance as a distinct diagnosis (Marks, 2019). Other eating disorders included 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, refined form. This edition introduced crucial diagnostic criteria, including the required feature of significant concerns about body shape and weight, solidifying its distinction from general purging behaviors.
Binge Eating Disorder's Path to Independence
The DSM-IV also marked the first mention of binge eating disorder (BED), though it was not yet recognized as an independent diagnosis. Instead, it was included in an appendix as a "proposed diagnosis for future study," signifying that clinical observation and research were pointing towards its distinct nature, but more validation was needed.
In this same edition, anorexia nervosa and bulimia nervosa were moved out of the "disorders of infancy, childhood, or adolescence" category and established as their own distinct category, reflecting their recognition as conditions affecting individuals across the lifespan. Other feeding disorders like pica and rumination disorder remained within the childhood and adolescent categories.
Finally, binge eating disorder achieved full independent diagnostic status in the DSM-5, published in 2013 (SAMHSA, 2013). This version of the DSM also reunited the categories of "Eating Disorders" and "Feeding and Eating Disorders of Infancy or Early Childhood" under a new, comprehensive umbrella category of "Feeding and Eating Disorders." The DSM-5 further expanded the diagnostic landscape by including avoidant restrictive food intake disorder (ARFID) for the first time, demonstrating the ongoing evolution of our understanding of complex eating pathologies.
The historical trajectory of eating disorders reveals a fascinating interplay between cultural contexts, scientific discovery, and evolving medical understanding. From ancient spiritual practices to distinct clinical entities, the journey of recognizing and diagnosing these conditions underscores their deep roots in human experience and the ongoing commitment to providing effective support and treatment.
