Anorexia Nervosa (AN) is a serious psychiatric disorder characterized by a persistent restriction of energy intake leading to significantly low body weight, an intense fear of gaining weight, and a disturbance in the way one’s body weight or shape is experienced. Although the condition was not formally named until the late 19th century, historical accounts of self-starvation practices date back centuries, often viewed through a spiritual or moral lens. The understanding of AN has transformed dramatically over time, moving from a purely physical ailment to a complex biopsychosocial disorder. This shift in perspective has led to substantial changes in how the medical and psychological communities have attempted to treat this life-threatening condition.
Early Focus on Physical Restoration (Pre-1900)
The earliest medical attention focused on the resulting physical wasting, viewing the patient’s refusal to eat as a nervous affliction rather than a primary psychological disturbance. Richard Morton, an English physician, is credited with one of the first medical descriptions in 1689, terming the wasting disease “nervous consumption” and noting it could occur without other apparent physical cause. The condition was formally established in 1873 by Sir William Gull in England, who coined the term Anorexia Nervosa, and concurrently by French physician Ernest-Charles Lasègue, who published on “hysterical anorexia.”
Treatment methods of this era were primarily aimed at immediate physical restoration to combat the starvation and emaciation. Physicians often prescribed enforced rest, isolation from the family environment, and a strict diet to promote weight gain. In more severe cases, feeding was accomplished through force or via a stomach tube, as the primary goal was to reverse the life-threatening state of starvation. The emphasis was on external control and physical intervention, reflecting the belief that the patient’s will to refuse food was a symptom to be overpowered for survival.
Psychoanalytic Interpretations (Early to Mid-20th Century)
A major shift in understanding occurred in the early 20th century with the rise of psychoanalytic theory, which began to dominate psychiatric thought. Under the influence of Freudian concepts, anorexia was re-conceptualized as a psychogenic disorder, rooted in deep, unconscious conflicts and unresolved developmental issues. This perspective often linked self-starvation to a rejection of adult femininity, sexuality, or a symbolic struggle against the mother-daughter relationship.
Treatment involved long-term, intensive talk therapy, focusing on uncovering the underlying psychological trauma and repressed emotions fueling the refusal to eat. The goal was not immediate weight gain, which was often considered a secondary symptom, but rather the resolution of the core emotional disturbances. Pioneering figures like Hilde Bruch emphasized that the disorder was a struggle for personal autonomy in individuals who felt helpless. However, psychoanalytic treatment often faced criticism for its length and limited effectiveness in addressing the immediate, life-threatening medical risks of starvation.
Institutional Control and Behavioral Conditioning (Mid-20th Century)
By the mid-20th century, a new paradigm emerged in institutional settings, heavily influenced by the principles of behaviorism. This approach focused on observable behavior—specifically weight gain—as the primary measure of success, moving away from the internal, unconscious conflicts of psychoanalysis. Treatment programs implemented strict operant conditioning protocols, where the patient’s environment was highly controlled.
Privileges, such as access to visitors, phone calls, or television, were made strictly contingent on incremental weight gain targets. Conversely, a failure to gain weight resulted in the removal of these privileges, often leading to social isolation and bed rest. This methodology reinforced the desired behavior (eating and weight restoration) through tangible rewards, bypassing the patient’s psychological resistance. While effective in promoting short-term weight restoration during hospitalization, this control system did not consistently prevent high relapse rates once patients returned home.
Transition to Structured Outpatient Care (Late 20th Century)
The limitations of both the open-ended psychoanalytic approach and the coercive behavioral programs led to a re-evaluation of treatment strategies. The late 20th century saw a shift toward structured, time-limited, and evidence-based models that prioritized outpatient management whenever medically safe. This movement established the groundwork for today’s gold-standard treatments.
A key development was the introduction of Cognitive Behavioral Therapy (CBT), which focused on identifying and modifying the distorted thoughts and dysfunctional behaviors surrounding food, weight, and body image. Another highly influential model was Family-Based Treatment (FBT), also known as the Maudsley approach, which empowered parents to take charge of the refeeding process at home. These models represented a move away from long-term institutionalization and focused on treating the disorder as an illness that had temporarily hijacked the patient and their family system. This combined focus on rapid weight restoration and specific psychological interventions marked the end of the historical era of purely physical or purely introspective treatments.