Chapter 1. Treatment of Eating Disorders: An Historical Perspective

Food-related preoccupations and concerns about body weight and shape have forever been part of society. People with sensitive or extreme temperaments sometimes become zealously preoccupied with prominent cultural attitudes and practices, such as those pertaining to feasting, fasting, food-related taboos and rituals, and concerns with weight and shape. At times, these individuals are ineffective at coping with these concerns and begin to behave maladaptively, consequently falling into states of psychological and physiological impairment (i.e., disorders). For these susceptible outliers, sociocultural pressures and fads may funnel their personal vulnerabilities into the shape of eating disorders (EDs).

Before examining the sociocultural phenomena that give EDs form, we must first consider what makes people susceptible to them. Three studies are illustrative. The first evaluated childhood obsessive-compulsive personality traits and found that childhood perfectionism and inflexibility (rigidity) were particularly strong predictors of ED, as well as being rule-bound, displaying doubt and cautiousness, and having a drive for order and symmetry. This was more pronounced for anorexia nervosa (AN) than for bulimia nervosa (BN). Each trait increased the additional risk of developing an ED by an approximate factor of seven (Anderluh et al. 2003). The second study identified childhood anxiety symptoms at age 10. The authors linked physical anxiety symptoms to the development of BN and linked worrying to the development of AN during adolescence (Schaumberg et al. 2019). A third study identified several concurrent risk factors for BN, necessitating the presence of both general psychiatric vulnerabilities and specific factors concerning attitudes and behaviors about weight and dieting. People who developed mood, anxiety, and substance use disorders were found to have increased likelihood of personal vulnerabilities (e.g., childhood characteristics, premorbid psychiatric disorders, behavioral problems, lifetime parental psychiatric disorders) and environmental factors (e.g., parental problems, disruptive events, parental caring and involvement patterns, recent parental psychiatric disorders, teasing or bullying, and sexual or physical abuse). Histories of childhood abuse and parental alcoholism were particularly common. In addition to these general psychiatric vulnerabilities (which usually result in depression), young women who developed BN had higher rates of environmental risk factors such as dieting, obesity, and parental ED (Fairburn et al. 1997).

These and other studies suggest that when vulnerable individuals who tend to be obsessional, perfectionistic, moody, and anxious are exposed to cultural attitudes and values that stress feasting, fasting, food taboos and rituals, and preoccupations with weight and shape, some embody and transmute these sociocultural phenomena into serious EDs.

In the beginning of human existence, some food was available, but often not enough. Food scarcities may have driven evolutionary pressures toward the appearance of “thrifty genes” that offered easier storage of body fat during plentiful times as insurance against lean times, thus fostering overweight and obesity during periods of abundance. Festive gorging might have occurred after successful large game hunts, or at harvest times once agriculture developed. Experts have pondered the significance and meaning of the prehistoric “Venus of Willendorf” carving (dated to approximately 28,000–25,000 B.C.E.), but it seems probable that this portly feminine figure with huge, pendulous breasts was a figure of adoration and admiration rather than scorn. After societies evolved from egalitarian sharing to rich and poor strata, the rich developed fancy banquets; in Ancient Rome, they went so far as to institute vomitoria for participants who overgorged, thus architecturally supporting and culturally condoning purging behavior.

With contemporary food abundances in developed areas, rates of obesity and, correspondingly one may assume, of binge eating disorder (BED), are increasing. Pima Indians (the Othama or Akimel O’odham people) in Southern Arizona have a great deal more significant obesity and diabetes mellitus than their counterparts in northern Mexico, just across the border, whose livelihoods require considerably more daily caloric expenditure. In the “supersize” culture of fast foods and oversized portions that is promulgated in the United States and has been exported to the rest of the world, rates of obesity have grown significantly.

Variously but widely practiced in many cultures and religions, intentional fasts devotionally demonstrate self-denial and may produce altered states of consciousness. Fasts are practiced in Baha’i, Eastern Orthodox Christianity, Evangelical Christianity, Hinduism, Islam, Jainism, Judaism, Native American religions, Roman Catholicism, and Taoism. Moses, Jesus, and Buddha were all said to have engaged in prolonged fasts associated with their spiritual pursuits.

Historically, dating from the fifth century B.C.E. in India, the Jain religious practice of Sallekhana involves voluntarily fasting to death by gradually reducing one’s intake of food and liquids, representing the thinning of human passions and the body. Chandragupta Maurya (340–297 B.C.E.), who founded the historically significant Mauryan Empire, is said to have renounced his throne to spend several years following his Jain guru and to have died by self-starvation. Large populations, including entire families, followed his example. A takeaway lesson here is that high-profile, influential leaders who adopt dramatic eating practices often become trendsetters and lead others to devotionally or blindly follow, even to the followers’ significant detriment.

Extreme versions of fasting and self-denial have clearly generated near-epidemic, clinically significant fashion trends. In anorexia mirabilis, during the fourteenth and fifteenth centuries, women intending to demonstrate Christian devotion through self-denial became obsessed with mortification of the body and abhorrent of the flesh. In parallel with some cases of contemporary AN, religious fasting in these women triggered extreme and persistent self-denial of food. Many achieved altered states of consciousness, often experienced as ecstatic “highs.” The more spiritually perfectionistic and single-minded among them starved themselves and died in large numbers (Espi Forcen and Espi Forcen 2015). The Roman Catholic Church canonized several hundred of these women as saints, the most prominent among them St. Catherine of Siena. Clinical descriptions of these women in “holy anorexia” suggest strong resemblances to contemporary descriptions of AN.

Taboos and rituals concerning food and eating are extremely common and ancient across societies. Mosaic laws of kashruth (defining kosher foods, animal slaughter, and food preparation, such as prohibiting pork and shellfish) date to more than a millennium B.C.E. Certain Jain, Buddhist, and Hindu traditions advocating nonviolence to all living things and associated taboos on eating beef and requirements of strict vegetarianism, particularly among the Brahmin class, date to at least 500 B.C.E. Some anthropologists argue that such taboos originated in economic considerations or for health reasons, whereas others believe food taboos usefully set kinship groups apart from one another, differences that defined marital options. Strictly observant Brahmins and Jains abstain from onions and garlic as well (perhaps reflecting allium sensitivities on the part of some ancient thought leaders).

Regardless of their origins, millions of people accept food taboos “off the shelf,” developing deep disgust and fear of certain foods and feelings of shame and guilt over related transgressions. In contemporary society, subgroups with food aversions are increasingly common (e.g., vegan, gluten-free, sugar-abstinent, various allergies). Clearly, rule-following individuals with obsessional and compulsive tendencies might be particularly prone to adopt food rules involving food elimination, portion-size limitations, and so on, growing rules on top of rules, to the point of caloric and micronutrient deficiencies associated with avoidant/restrictive food intake disorder (ARFID), orthorexia nervosa, or AN.

For both sexes, physical appearances denoting attractiveness and health have been associated with higher social status and preferential mate selection for virtually all of recorded history. Throughout the ages, artists have depicted what different epochs and ethnicities variously considered most desirable. Over the past two centuries, we can easily trace fads and fashions showing strong influences of high-status opinion leaders on weight- and shape-related practices. The following are a few salient illustrations.

In the mid-nineteenth century, Princess Elizabeth of Austria, Queen of Hungary (1837–1898; peak influence circa 1859–1860), who was then one of the highest-status women in Europe, helped set the stage for widespread dieting, corseting, and “tight-wasting” among young women of royal connection and persuasion. Known to binge-eat and purge, she weighed herself obsessively multiple times daily; throughout her adult life, her weight varied from BMIs of 14–17. Numerous princesses followed her lead, and high-status young females started to show clinical symptoms that culminated in the original independent descriptions of AN among upper-class women by Gull in England and Lasègue in France (Gull 1873; Lasègue 1873).

Certain technologies became more widespread and might have also increased attention to shape and weight. Although crude mirrors were available beforehand, the first silver-glass mirror was invented in 1835, and the general availability of household mirrors developed in the mid- to late nineteenth century. Similarly, street-corner “penny scales” first became popular in the 1920s and 1930s (“measure your weight for a penny”), and affordable household bathroom scales first became widely available in the 1940s. Just as internet and cellphone addictions required the invention and widespread availability of those technologies, mirrors and scales permitted easier obsessional and compulsive attention to weight and shape.

Starting in the late nineteenth century and blossoming in the twentieth, trickle-down influences on shape and weight also became much more pronounced with modern advertising and mass media. One of the first fads to widely promote slender female body shapes, the “flapper” fashions of the 1920s, was accompanied by increased reporting in college newspapers of purging behaviors among college women. This trend abated in the 1930s, 1940s, and 1950s, during which time curvaceous body shapes among high-status and celebrity women became more prominent.

However, during the 1960s, several mass culture influences converged to promote the social desirability of slender appearance in high-status (predominantly white) women. Along with the sexual revolution, Helen Gurley Brown, editor-in-chief and top-tier trendsetter at Cosmopolitan magazine, pushed images of slim fashion models, lauding the thin look. Among celebrities, slim American and British actresses and models became top fashion icons. In contrast to previous, somewhat older, and more solidly built presidential wives, Jacqueline Kennedy cut a slim, youthful figure. The advent of early television and the appearance of many actresses as heavier on screen than they were in real life may have led some actresses to slim down to improve their on-screen appearance. George Balanchine, the most prominent American ballet director, favored increasingly thin dancers who were much thinner than their European counterparts, and Hugh Hefner, publisher of Playboy magazine, chose slimmer women in the 1960s and 1970s to personify female sexuality as “Playmate” centerfolds.

As popular culture became stocked with growing numbers of fashion magazines portraying unrealistically slim, airbrushed fashion models, many women became obsessed with these magazines, and those vulnerable to EDs consistently found themselves feeling worse after reading them. Television fashion shows flourished that featured predominantly slim models (as currently represented by shows such as Project Runway and America’s Next Top Model). When first exposed to slim feminine Western images on television, well-built Polynesian Island teenage females who had been content with themselves previously became increasingly self-conscious and dissatisfied with their appearance and for the first time ever began to develop EDs. In post-apartheid South Africa, Westernization may be impacting attitudes toward shape and weight, resulting in greater likelihood of EDs (Morris and Szabo 2013). Similar shifts have been seen in Latina/Hispanic populations, leading some authorities to view EDs not only as culture bound syndromes but also as markers of cultural change (Miller and Pumariega 2001).

Today, adding to the ubiquitous sniping, competitive, gossipy, and snarky “friendships” that add to normative adolescent peer pressures, youth are contending with powerful social media sites, such as Facebook, Instagram, and Snapchat, that are dominated by visual images and afford further opportunities for negative self-evaluation by appearance-preoccupied, insecure, self-doubting, anxious young women who strongly link self-esteem to physical appearance. As these young women find their own appearances to be wanting and inferior, they appear more vulnerable to developing EDs.

The treatment of any disorder depends upon several factors: 1) contemporaneous general theories of illness (e.g., Hippocratic-Galenic theory of the four humors); 2) specific concepts of etiology for the disorder (psychosocial, neurochemical, psychodynamic); 3) the diagnostic criteria and terminology in use (anorexia nervosa vs. pubertätsmagersucht vs. hysterical anorexia); and 4) the training methods of treating clinicians. Challenges to whatever treatment methods are currently in vogue lead to a period of defensive (and often angry) skepticism about the need for change and to replacement by a new method (paradigm shift). Physicians once believed that peptic ulcers were caused by excess acid production in the stomach from either stress or dietary indiscretion, and thus they prescribed antacids, low-acid foods, and acid-buffering medications. Only after Warren and Marshall, using heroic methods of self-inoculation, identified the Helicobacter pylori bacterium as the real cause did that field evolve to its present-day effective antibiotic treatment (Marshall and Adams 2008).

This section reviews the evolution of ED treatment approaches and programs in view of the factors just described and offers an appreciation of the expanding concept of EDs and newer approaches to treatment. The convention used herein considers EDs to be syndromes involving psychological and medical components, not simply disordered eating as exemplified by Roman-era gluttony or medieval asceticism through fasting. Although AN is the least common of these disorders, it was historically the first described, with a wide variety of treatment methods employed over the centuries. The term anorexia nervosa as it is commonly used in English implies a disorder that generally moves from voluntary onset into involuntary continuation. An understanding of EDs in the twenty-first century is greatly assisted by an appreciation of their history, lest the current diagnostic criteria and treatment methods be considered as arising de novo like Aphrodite from the sea, fully formed and enduring.

Keys et al.’s (1950) original starvation study demonstrated that nutritional rehabilitation can lead to changes in more than just medical sequelae, including improvements in depression, anxiety, irritability, concentration, and social interactions, thus recognizing that improving the body does, in fact, improve the mind. Much of the treatment research in EDs has focused on adults with low-weight AN and has usually shown improvements in ED and comorbid psychiatric pathologies (Channon and de Silva 1985; Meehan et al. 2006; Pollice et al. 1997). The specific linking of weight gain with psychological improvement is sometimes difficult to evaluate because many studies do not directly evaluate this connection. Early results were more mixed, with some showing a direct correlation (Eckert et al. 1982), others showing weight changes not being associated with psychological changes (Coulon et al. 2009; Mattar et al. 2012), and still others showing mixed results (Kawai et al. 2008; Laessle et al. 1988). With regard to severe and enduring AN in adults, Touyz et al. (2013) demonstrated an approach that did not specifically emphasize weight gain as directly but still resulted in improvements in eating and comorbid psychiatric psychopathologies. However, patients did, in general, gain weight, and their nutrition improved.

Family-based treatment for children and adolescents with EDs has shown improvements in both ED and comorbid psychiatric pathology (Le Grange et al. 1992, 2014; Lock et al. 2005), with some data showing that patients with greater eating psychopathology and particularly binge-purge subtypes of AN (considered more severe in pathology) benefited to an even greater degree from nutritional rehabilitation (Accurso et al. 2014; Eisler et al. 2000; Le Grange et al. 1992; Lock et al. 2006). Furthermore, even early weight gain trajectory (a proxy for total nutritional rehabilitation) can predict overall outcome (Accurso et al. 2014). However, some studies still show improvement in eating and comorbid psychiatric psychopathologies without as robust a change in nutrition restoration (Robin et al. 1999). Overall, the data, hough murky at times, suggest that nutritional rehabilitation is an important consideration for treating not only the physical sequelae of EDs but also underlying psychopathology and comorbid psychiatric conditions.

Viewed through the medical lens of “disease staging,” the identification of disease and provision of early intervention are usually linked with improved outcomes. Although consensus on a rubric for staging ED severity has been difficult to achieve, overall data conclude that early treatment is beneficial, with most descriptive studies supporting the conclusion that a longer duration of illness is associated with more severe medical complications, predicts a worse outcome, and is associated with higher relapse rates. Thus, aside from prevention strategies, early intervention is the best way to treat EDs (Berends et al. 2018).

Historically, data have suggested that younger age at onset is associated with more severe ED-related obsessions and comorbid psychiatric conditions. However, some have suggested that the severity of illness in younger patients may, in fact, be the result of delayed identification and a longer duration of illness prior to first treatment (Neubauer et al. 2014). Recent data have supported this finding, showing that the duration of illness itself (and not age) indicates a higher risk of relapse (Berends et al. 2018).

Treasure and Russell (2011) presented a cogent description of the potential theoretical framework behind the idea of early intervention, particularly regarding the developmental process that takes place in the brains of young people. The malnutrition resulting from EDs comes at a time when tremendous developmental changes are occurring in the brain. The loss of brain matter itself interrupts the normal maturation process. The optimal hormonal milieu is also lost, because steroid hormone synthesis depends on adequate substrate, namely cholesterol. Disruption of this milieu impacts areas of the brain involved in self-regulation, impulsivity, mood, and excitability. Finally, animal models have demonstrated the impact of disordered eating on the sensitization of reward pathways within the developing brain, which results in progressive cementing of those pathways over time (Lutter and Nestler 2009; Treasure et al. 2010). This suggests that early intervention may be the only way to truly reverse these paths.