Historian Alice Weinreb of Loyola University Chicago in Chicago has traced the evolution of anorexia nervosa using materials from several dozen archives across eight countries. Weinreb, whose 2017 book Modern Hungers: Food and Power in Twentieth-Century Germany examined hunger and nutrition in 20th-century Europe, is now exploring how anorexia nervosa grew from an obscure condition into a widely recognized diagnosis that now occupies a prominent place in society.

‘The Golden Cage’ Becomes a Model

In 1978, the German-American pediatrician and psychiatrist Hilde Bruch, MD, (1904-1984) published The Golden Cage: The Enigma of Anorexia Nervosa, the first book on anorexia nervosa aimed at a general audience. Reprinted multiple times, translated into 12 languages, and selling more than 150,000 copies worldwide, it played a decisive role in changing public perception.

Typical patients were primarily the daughters of wealthy, educated, and successful families: young, white, attractive, high-achieving, and socially well-off. Psychologist Steven Levenkron took up this image as early as 1979 in his young-adult novel The Best Little Girl in the World, which was later even adapted into a film. Anorexia thus increasingly came to be seen as a disease of those young women who, from the outside, seemed to lack almost nothing.

Then, media outlets worldwide reported on the death of singer Karen Carpenter (1950-1983) and its connection to anorexia nervosa. For Weinreb, this served as confirmation: Successful and privileged young women, of all people, were capable of starving themselves into a life-threatening illness.

How Doctors Learned to ‘Recognize’ Anorexia

Even in medicine, this clinical picture first had to become established. Training materials now listed anorexia nervosa among the mental illnesses that aspiring psychiatrists were expected to recognize and diagnose. In one document examined by Weinreb, anorexia nervosa was already included among the diagnoses that students were required to make on their own during their training.

In continuing medical education programs, anorexia was not only described but also explained. For instance, British psychiatrist Ross Mitchell, framed the disorder as a self-perpetuating cycle: Starving oneself can create a sense of control and safety, which in turn fosters resistance to change and ultimately leads to further starvation. Models like this helped clinicians make sense of a condition that was still relatively unfamiliar at the time.

Doctors were taught far more than just the classic symptoms of anorexia. Through educational films and lectures, they were also shown a particular patient profile: typically young, white, and middle class. At the same time, they were warned that treatment could be especially challenging. Patients were often described as uncooperative, manipulative, or irrational.

As a result, two very different images took shape side by side: the poised, high-achieving young woman and the patient who appeared determined to resist medical care.

Feminism: Cause and Perspective

With the women’s movement, the debate took on a new dimension. Bruch herself had suspected that the rising expectations placed on young women might contribute to the increase in the disorder. She argued that the women’s movement had raised their ambitions to an almost unattainable level, thereby overwhelming even highly conformist girls.

Feminist authors, on the other hand, interpreted anorexia as an expression of societal pressures. They pointed to unattainable beauty ideals, consumer culture, and contradictory expectations regarding female bodies. Thus, two interpretations stood in opposition: Bruch saw the women’s movement as a possible source of additional pressure to perform, whereas for feminist authors, the causes lay in societal expectations of women.

These debates also led to the creation of practical support services. Self-help efforts connected affected individuals and their families with specialized physicians, organized support groups, and produced educational materials. At first, they had to painstakingly assemble lists of appropriate contacts, and typewritten sheets with the names and contact information of a handful of specialists circulated within these groups. By the mid-1980s, some of these efforts had grown into nationwide organizations with multiple regional chapters.

Bulimia Takes Over Campus

Anorexia nervosa had now publicly become the symbol of eating disorders. At the same time, however, bulimia nervosa — which had not been described as a distinct medical diagnosis until 1978 — was increasingly coming to the forefront at American universities. Previously, it had sometimes been considered a variant of anorexia, also known as “bulimorexia.”

One of the earliest landmark studies was the Radcliffe study. In 1981, medical anthropologist Norma Ware, PhD, then assistant dean at Radcliffe college, received a substantial grant from the US-based National Science Foundation, the federal agency that funds scientific research and education across a wide range of disciplines. The study launched in 1982, beginning with questionnaires given to 400 women and 200 men, followed by interviews and medical evaluations. Using the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III), investigators found that 8% of female students and 0.7% of male students met criteria for bulimia. The results quickly drew attention and spurred similar research at other universities.

Those findings soon translated into action. Colleges and universities began offering counseling services and student support groups, distributing self-assessment tools, and developing guidelines to determine when affected students should leave campus for treatment. Counseling center and residence hall staff also got involved, with training programs created to help them identify possible eating disorders. In this way, the management of anorexia and bulimia started to take hold within university mental health services.

A Nearly Unanimous Consensus

For Weinreb, what stands out most is the way such a diverse group of stakeholders interacted around the issue. Medical professionals, the media, self-help organizations, and feminist authors each framed eating disorders differently, but they often reinforced the same core message: Young women were especially vulnerable, and these conditions could be serious — even life-threatening. A 1986 New York Times announcement already grouped eating disorders with drug abuse and suicide as major threats facing young people. Adding to the alarm was the concern that parents might not recognize the problem for a long time.

Unlike HIV/AIDS, which sparked intense political and social conflicts at the same time, the call for greater attention to eating disorders met with little resistance. As a result, self-help organizations increasingly found a voice at the political level as well.

The Profile Was Narrowly Defined

The dominant patient profile, however, had narrow boundaries. Data on men and non-White populations were certainly available, but they did little to alter the perception of the young, White, and educated female patient. At historically Black colleges and universities, for example, lower rates of anorexia nervosa were observed, yet comparable rates of bulimia and other disordered eating behaviors were found.

Men also appeared in the contemporary literature, but often with an additional label. Doctors and researchers frequently described male patients with eating disorders as homosexual or bisexual and linked the condition to their sexuality. The basic understanding of eating disorders thus remained strongly female-centric.

Just how much the social standing of these disorders had changed within a few years was ultimately evident in the political arena. In 1991, the US Congress designated a week in February as Eating Disorders Awareness Week. Within a decade and a half, the previously little-known diagnoses of anorexia nervosa and bulimia nervosa had become a widely recognized health and social problem in the US.

This story was translated from Univadis Germany, part of the Medscape Professional Network.