Eating disorders are sometimes represented as culturally-bound syndromes of the post-modern era, however research finds that eating patterns commonly associated with eating disorders, such as bingeing, purging and fasting, date back to Roman and Christian eras, respectively (Bemporad, 1997; Craighead, Martinz, & Klump; 2013; Lock & Kirz, 2013). It wasn’t until the late 17th Century that these eating behaviours were interpreted within a medical framework and acquired associated remedies (Bemporad, 1997).
The Medicalisation of Eating Disorders
Anorexia Nervosa (AN), Bulimia Nervosa (BN) and Binge Eating Disorder (BED) have become recognised as psychiatric disorders at different times throughout the 19th and 20th Centuries.
The first complete medical descriptions of AN were recorded separately in 1873 by French physician Charles Lasegue and British physician, Sir William Gull. Both physicians described an illness - ‘anorexia hysterica’ – as a condition primarily affecting girls and young women, who presented with significant weight loss, constipation, and restlessness but without an identifiable organic pathology (Lock & Kirz, 2013; Walsh, 2013). In the early 20th Century German pathologist Morris Simmonds conceptualised AN as an endocrine illness and the disorder was treated with endocrinological medications (Bemporad, 1997; Lock & Kirz, 2013; Walsh, 2013). During the post-War period, the medical model of AN was challenged by psychoanalytical interpretations which understood the patients’ refusal to eat as a defence mechanism against their dreaded, unconscious wish for oral impregnation (Bemporad, 1997; Theander, 2004). Subsequent treatment for AN was an individual psychoanalytic therapy.
Arguably, the most profound theorisation of AN was presented in the work of psychiatrist Hilde Bruch (1973; 1978). Coming primarily from a psychodynamic approach Bruch (1973) explained AN as resulting from patients’ inability to master the tasks of adolescence, such as individuation and separation from the family. From this perspective, the patient used disordered behaviour to gain a sense of control over his/her own body in an attempt to control the chaos in their life (Bemporad, 1997). The psychodynamic approach led to the development of individual psychodynamic psychotherapy (IPP) for the treatment of AN. At a similar time, the family systems model of psychotherapy emerged – which interpreted AN as the consequence of family psychopathology. Subsequent treatment involved family therapy which emphasised family processes, communication and the negotiation of adolescent development issues (Lock & Kirz, 2013). These latter conceptualisations of AN are significant because they contributed to a range of contemporary treatment approaches, such as individual psychodynamic psychotherapy (IPP), Family Based Therapy (FBT) and to a lesser extent, Cognitive Behavioural Therapy (CBT).
Although records of bulimic symptoms, such as overeating and purging, pre-date symptoms associated with AN, BN was not recognised as a separate disorder until its addition to the Diagnostic Statistical Manual (DSM) III in 1987. Its recognition as a disorder can arguably be accredited to the work of feminist and cultural scholars of the 1970s (Boskind-Lodahl & White, 1973) who framed binge-purge behaviours among normal-weight women as ‘bulimarexia’. In these accounts, BN was conceptualised as a culture-bound syndrome resulting from the obsession with thinness in modern Western culture (Boskind-Lodahl & White, 1973). Although socio-cultural ideals around gender and body shape continue to be recognised in the aetiology of eating disorders, they are now seen as only one of several contributing factors (Heaner & Walsh, 2013).
Similar to treatment for AN, current treatment for BN predominantly draws on CBT, FBT and/or IPP. Wilson, Grilo and Vitousek (2007) found that patients presenting with BN are particularly responsive to CBT as a first line of treatment, and that the efficacy of this treatment – at least initially – is sometimes enhanced by the adjunction of medication (Craighead et al., 2013). Recently, several other modifications of CBT have been developed to treat BN including integrative cognitive therapy and dialectal behaviour therapy (DBT), however, these treatment avenues require further evaluation (Craighead et al., 2013).
Binge Eating Disorder
Compared to AN and BN, BED is a newly recognised psychological condition, acknowledged for the first time as a separate category of eating disorder in the DSM V (APA, 2013). Previously, patterns of disordered eating that did not fit the criteria for an AN or BN – including binge eating without compensatory behaviours –were grouped under the ‘Eating Disorder Not Otherwise Specified (EDNOS) category (Craighead et al., 2013). Binge eating was predominantly recognised as a clinical problem within the context of obesity, since obesity was typically the presenting problem. Craighead et al (2013) note that distinguishing BED as a separate diagnosis is useful for drawing attention to treatments specific to this disorder.
Recent research finds that most treatments used for BN have also been successfully applied to BED, although no treatment for BED has yet to result in meaningful weight loss. In some studies variants of CBT (Allen & Craighead, 1999; Klein, Skinner & Hawley, 2012) were found to be helpful for reducing episodes of binge eating but have not had a significant impact on patients’ weight. Similar outcomes have been seen in the application of medication for binge eating (Craighead et al., 2013), although given the recency of BED as a diagnosis, these findings remain preliminary.
Latest developments in the treatment of eating disorders
A literature search on treatment models for eating disorders yields confusing results. Although much has been written about the different frameworks that historically, and currently, frame our conceptualisations of eating disorders, at present there appears to be no theoretical agreement about the best approach for treatment. This may speak, in part, to current understandings of eating disorders as complex, multi-faceted illnesses requiring targeted and unique treatment. Recently there has been a renewed interest in the contribution of neurobiological factors to the development and maintenance of eating disorders (Craighead et al., 2013), as well as the role that genetic variations may play in the illness (QIMR Berghofer Medical Research Institute, 2016). Both of these recent developments are likely to hold significant implications for the kinds of treatments put forward to patients affected by said disorders.
Allen, H.N. & Craighead, L.W. (1999). Appetite monitoring in the treatment of binge eating disorder. Behaviour Therapy, 30(2): 253 – 272.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Association.
Bemporad, J.R. (1997). Cultural and historical aspects of eating disorders. Theoretical Medicine, 18: 401 – 420.
Boskind-Lodahl, M., & White, W.C. (1973). The definition and treatment of bulimarexia in college women – a pilot study. Journal of American Health Association, 27: 84 – 97.
Craighead, L.W., Martinz, M.A. & Klump, K.L. (2013). Bulimia Nervosa and Binge Eating Disorder (2013). In W.E. Craighead, D.J. Miklowitz & L.W. Craighead (Eds.), Psychopathology: History, Diagnosis and Empirical Foundations (pp. 445 – 481). Somerset, U.S: Wiley.
Heaner, M.K & Walsh, T. (2013). A history of the identification of eating disturbances of bulimia nervosa, binge eating disorder and anorexia nervosa, Appetite, 65: 185 – 188.
Klein, A.S., Skinner, J.B., & Hawley, K.M. (2012). Adapted group-based dialectal behaviour therapy for binge eating in a practicing clinic: Clinical outcomes and attrition. European Eating Disorders Review, 20(3): e148 – e153.
Lock, J. & Kirz, N. (2013). Anorexia nervosa. In W.E. Craighead, D.J. Miklowitz & L.W. Craighead (Eds.), Psychopathology: History, Diagnosis and Empirical Foundations (pp. 482 - 510). Somerset, U.S: Wiley
Theander (2004). Trends in the Literature on Eating Disorders over 36 Years (1965 – 2000): Terminology, interpretation and treatment, European Eating Disorders Review, 12: 4 – 17.
QIMR Berghofer, Medical Research Institute (2016). The Anorexia Nervosa Genetics Initiative (ANGI). Retrieved from: https://angi.qimr.edu.au/News/AboutAngiResearchStudy
Walsh, B.T. (2013). The enigmatic persistence of anorexia nervosa, American Journal of Psychiatry, 170: 477 -484.
Wilson, G.T., Wifley, D.E., Agras, W.S. & Bryson, S.W. (2010). Psychological treatments of ginge eating disorder. Clinical Psychology Review, 32(4): 343 – 357.
Ziolko, H.U. (1996). Bulimia: a historical outline, International Journal of Eating Disorders, 20(4): 345 – 358.
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