Is Anorexia a Modern, Culture-Bound Disorder?




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The universality and the origins of anorexia nervosa have been the subject of years of debate. Some argue that the eating disorder is a culture-bound syndrome specific to the Western, industrialized world, while others maintain that there is evidence that the disease is not confined to more recent times or one part of the world.

While acknowledging “symptomatic continuities” which extend back in time prior to the mid-1800s, others maintain that certain elements essential to the classification of anorexia nervosa were absent prior to the latter half of the 19th century.

Whether or not anorexia nervosa (AN) and bulimia nervosa (BN) existed before this time hinges on a crucial factor, argues Tilmann Habermas: “The clinical feature that renders both disorders distinctly modern and Western is the overvalued idea of being too big when at normal body weight, which serves as the primary conscious motivation for restricting food intake.”

Self-starvation is by no means modern, however the components of distorted body image and fat-phobia as principal motivators may not have emerged until more recently. This is consistent with the DSM-IV criteria for AN, which includes “refusal to maintain body weight at or above a minimally normal weight”, and “intense fear of gaining weight or becoming fat even though underweight,” along with “disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.”  

We should not, therefore, include cases of self-starvation throughout the ages which stemmed from other motivations, such as depression or grief, digestive issues, obsessive disgust with food or eating that does not have a weight-loss motivation, or fear of poisoning.

Cases Prior to the 19th Century
Klump and Keel go as far back as the case of a 9th century Bavarian serf named Friderada whose inability to eat was described as part of a monk’s attestation to a miracle peformed by Walburgis. The fasting medieval saints have been part of the discussion surrounding whether AN emerged more recently or has been present throughout the centuries.

While self-starvation criteria is met, fat-phobia is often missing in these cases. Habermas distinguished cases of inedia among fasting religious ascetics from AN as we know it in modern times: “Being underweight was not a necessary or even a typical condition for claiming inedia.”

He also points out that anorexics tend to hide their food avoidance, while the religious ascetics tended to exhibit their abstinence as miraculous. “The miraculous fasting girls from the 16th to the 19th century,” says Habermas, “remained in their families, were ill or handicapped, and claimed not to be eating anything, although most of them were not emaciated. Girls with AN, in contrast, try to make believe they are eating normally, and provide a variety of medical, somatic, or aesthetic reasons not to eat.”

Consequently, he concluded that neurotic asceticism accompanied by weight loss had similarities with AN, but was “probably still more similar to neurotic asceticism without weight loss.”

When AN Coincides with Religious Asceticism
Later studies have looked at anorexia and religiosity, finding that religiosity was associated with lower minimum body mass index achieved, and that religiosity tended to increase as AN progressed. Another study found that anorexics modified their religious practices after the onset of AN, with decreased participation in communion or feasts and increased religious fasting.

The element of self-disgust with one’s body is not recorded in many older and religious cases, however one French catholic named Renata, documented by Schnyder in 1912, did exhibit a loathing of her shape, with a religious bend. She felt that weight contributed to sensuality and did not want to be “an object of desire,” and expressed feeling “ashamed to feel that I was looked at.”

The time of onset, at about age 16, as well as Renata’s obsession with biking 40 kilometers, self-induced vomiting, and self-starvation, point to anorexia and bulimia framed in religious terms. Habermas therefore suggests that intense religiosity and AN need not be mutually exclusive, however many of the religious ascetics did not meet the DSM-IV criteria for AN.

Change in Incidence, or Change in Documentation?
The late 19th century produced abundant medical literature on AN cases, leading to the question of whether the incidence of AN actually increased at that time, or whether the clinical documentation that accompanied the emergence of psychiatry in France led to increased notice of cases in conjunction with what was otherwise a stable incidence rate.

Habermas also points to “an interest in nutrition, which, combined with an interest in the psychology of their patients, made German physicians of internal medicine sensitive to motives for not eating.”

German doctors, he also noted, attributed cases of AN to Simmonds’ Disease between 1914 and 1945. Cases of AN motivated by fear of weight gain were recorded in Russia in the late 1800s, as well as in Italy. However, a change in primary sources around this time also occurred, with cases recorded by physicians in the context of medicine rather than by religious sources.

The medical literature of the latter half of the 19th century describes French school girls drinking vinegar and limiting food intake for aesthetic purposes, an emaciated Queen Elizabeth of Austria, obsessed with exercise and food restriction, motivated by a fear of growing fat. Habermas recounts that “in the second half of the 19th century, medicine began to label as pathological even moderate degrees of overweight, which were increasingly judged by reference to statistical tables such as those by Quetelet (1835) and Worthington (1875).” Interestingly, concern about excess weight first emerged among men, in contrast to today’s typical anorexic, the adolescent girl. In the early 1900s, some physicians associated corseting with AN.

Universality vs. the Globalization of Eating Disorders
Whether AN is a Western phenomenon, or found throughout the world has also been debated. Isaac cites research in which Keel and Klump concluded that AN was not a culture-bound syndrome, but bulimia was, suggesting that nonwestern bulimics had  been exposed to Western culture.

Smink et al. performed a meta-analysis of 125 studies and point to “cultural transition and globalization” as mechanisms by which eating disorders which were historically characterized as culture-bound started appearing in non-western countries and among minorities. They note a study on the Caribbean island Curacao in which no cases were found among the black population, while incidence rates among white and mixed-race residents where comparable to those found in the U.S. and the Netherlands. Other eating disorders, such as binge eating, have been associated with migration from Mexico to the U.S.

As Haberman stated, “whether AN and BN are universal or restricted to specific historical phases (and cultures) has been shown to depend on two main factors, namely, on the methodology of historical research and on the diagnostic criteria chosen.” In this context, some evidence suggests that although abnormal eating habits and fasting can be found throughout the ages, the motives and body image distortion that accompany what we currently know as AN may not have been present prior to the mid or late 1800s. Alternately, AN may have been present, but cultural context and the nature of sources, both of which shifted in the 1800s, may have simply obscured its presence.

References
Habermas, T. (1992). Further Evidence on Early Case Descriptions of Anorexia Nervosa and Bulimia Nervosa. International Journal of Eating Disorders, 11(4) 351-359.

Habermas T (2005). On the uses of history in psychiatry: diagnostic implications for anorexia nervosa. The International journal of eating disorders, 38 (2), 167-82 PMID: 16134113

Isaac D (2013). Culture-bound syndromes in mental health: a discussion paper. Journal of psychiatric and mental health nursing, 20 (4), 355-61 PMID: 23495975

Smink FR, van Hoeken D, & Hoek HW (2012). Epidemiology of eating disorders: incidence, prevalence and mortality rates. Current psychiatry reports, 14 (4), 406-14 PMID: 22644309

Image via Keith A Frith / Shutterstock.

Lindsay Myers, MBA, MPH

Lindsay E. Myers, MBA, MPH, is a national healthcare consultant. Ms. Myers has served as Chief Financial Officer, Director, and Consultant to hospitals, physician practices, hospices, social services agencies, and public health clinics. She lives in Sarasota, Florida.
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