CONTINUITY AND CONTINUUM

The above review and the contemporary nosological and epidemiological scene presented in the previous chapter raise the question of whether a connection exists between eating disorders, often viewed as modern pathologies, and pre-historic forms of anorexia and bulimia. In this section I argue that both anorexia and bulimia show

some aspects of historical continuity, which allows a conceptualization of the two pathologies around enduring issues of control that involve the object. The conceptualization ultimately introduces the notion of intrusion in the eating disorders conundrum.

The concept of continuity in eating disorders is complex and involves multiple levels of interaction, broadly defined in terms of time, space, intensity, and the relationship of classes of disorders with one another. These layers of interaction are articulated around a number of questions. Do modern forms of eating disorders bear continuity with seemingly comparable syndromes in history and across cultures? In a more specific way, does a single answer apply to the two emblematic categories of anorexia and bulimia, or is historical/spatial continuity relevant to one but not necessarily the other? In other words are the two disorders discrete, as suggested by psychiatric categories, or do they lay on a continuum, as also suggested by their conspicuous nosological overlap and fluidity - including in the frequently reported evolution, crossover, of anorexia into bulimia? Again, these various questions are interrelated and will be treated as such.

I mentioned earlier that, in contrast with a consensus that modern anorexia is reasonably connected to historical syndromes of self-starvation, there is disagreement among scholars over the existence of ‘pre-historical’ forms of bulimia. Proponents of

discontinuity for the latter syndrome have based their arguments on what they consider an important discrepancy in the mass of recorded evidence for the two syndromes, which they claim is more important in the case of anorexia, as well as on historical inconsistencies in criteria of inclusion, which they say are more characteristic of bulimia.

As for advocates of continuity such as Stein and Laakso (1988), they consider the cases they have documented as speaking for a historical continuity of bulimia.

While considering binge-purging syndromes as exclusive to modern times does not do justice to historical references evoked in the above review, it is difficult to ignore the arguments put forward by the proponents of discontinuity. After presenting and discussing these arguments, I show how, by aligning bulimia on anorexia as two antithetic impulses towards the object (Shipton, 2004) - an alignment supported by the taxonomical fluidity revealed in Chapter I -, it becomes possible to consider the former disorder as having reasonably comparable precursors in history.

The Mass of Evidence Argument

The above review is not comprehensive and does not allow a definite answer about the volume of available evidence for each syndrome. On the other hand, it does not point toward a particularly remarkable dearth of historical accounts on bulimia. In any case, even if forerunners of today’s bulimia are rare in comparison to their anorexic

equivalents, it is not clear whether this scarcity is the result or the cause of the late classification of Bulimia nervosa as a distinct disease (Keel, 2005) - with the official recognition of anorexia a century older than that of bulimia, the body of research on the former was bound to be larger³⁸. Also, the paucity of literature on precursors of bulimia, again if the characterization applies, could also be attributed to difficulties in spotting bulimics. Indeed, in the absence of conspicuous signs, such as emaciation in anorexia,

“bulimia nervosa may have existed but eluded detection”³⁹ (Keel, 2005, 30). Moreover, while anorexic motivations can be easily idealized - sacredness, protest against oppressive authority -, it seems difficult to romanticize bulimic drives, whether in their gluttony or purging aspects. It is worth mentioning in this respect the often-secret dimension of bulimic conducts and the shame that characterizes those who carry them (Chapter VII). To conclude, all the above factors may well contribute to a diminished visibility of bulimic behaviors, which would have necessarily impacted the volume of available historical references on these syndromes.

The Symptom Consistency Argument

As for the argument of symptom consistency across time, there is no doubt that there exists a difficulty that is specific to bulimia, which has to do with the complexity of                                                                                                                

38 Keel (2005) is nevertheless among those who argue against a historical depth in bulimia.

determining which pre-historic bulimic symptom or syndrome actually represents an antecedent of present day bulimia as a binge-purge disorder. This nosological difficulty is further complicated by the terminological confusion transpiring in historical accounts and encyclopedic entries - in some, bulimia refers only to the abnormally excessive absorption of food; in others, it also includes vomiting.

It is around the modern criterion of weight phobia that the differential in symptom consistency between anorexia and bulimia is particularly focused, justifying in turn their divergent historical status in the literature. For instance, noting that, when leaving the diagnostic yardstick of “fear of getting fat” out, anorexics are found as frequently in Western and non-Western cultures, not to mention historical cases of self-starvation, Keel (2005) infers that, in anorexia, similarities [intentional self-starvation, recovery in some cases and death in others, and a population of mainly adolescent girls and young adult women] far outweigh inconsistencies [weight concerns (as opposed to moral superiority⁴⁰), attention seeking, and fear of the danger of food to the body]. In contrast, the binge purge syndrome, which, she notes, always occurs in contexts of exposure to Western influence (whether in Western or non-Western countries), consistently involves weight concerns. Keel consequently considers the binge purge syndrome as a

40 It is important to point out however that, although it finds its expression in other, non-sacred ways, moral superiority is not absent from today’s anorexic picture.

modern/Western, culture-bound⁴¹ phenomenon, her case for discontinuity, whereas she views the syndrome of self-starvation as predating contemporary forms of Anorexia nervosa, her argument for continuity.

Like Keel (2005), although in a different and probably more complex manner, Habermas’ (1989, 1992; Habermas and Beveridge 1992) take on weight concerns underscores the modern criterion’s discriminatory position vis-à-vis continuity in anorexia and bulimia. While Keel’s angle emphasizes the cultural aspect, Habermas’

approach provides particular insight into the internal workings and dynamics of the contemporary symptom of weight phobia with other symptoms. In anorexia, the terror of becoming overweight, the new symptom in history, supersedes ascetic motivations for self-starvation, the symptom of the past. In bulimia, it is the combination of weight concerns with food reversal methods that is pivotal in changing a long-existing binge eating symptom into the modern binge-purge disorder.

There is I believe an inherent contradiction and arbitrariness in basing the continuity argument that discriminates between anorexia and bulimia on the existence or absence of the weight concerns criterion - its presence creating the modern/Western category of bulimia as a binge-purging syndrome, whilst its absence is considered irrelevant to the category of anorexia. Habermas himself alludes to the contradiction in                                                                                                                

41 Following Prince’s definition of a culture-bound syndrome as “a collection of signs and symptoms (excluding

remarking that, should this symptom, which constitutes a critical diagnostic criterion for both disorders in contemporary nosology, be taken into account to identify anorexic and bulimic syndromes in the past, then both eating disorders would be considered new from a historical point of view (Habermas, 1992). Extrapolating on Habermas’ insight on the dynamic articulation of symptoms in eating disorders and pushing the above contradiction a little further, I will now put forward the case for some form of continuity for all categories of eating disorders.

The Fluidity of Eating Disorders

Habermas’ (1989) perspective not only offers a good example of how past cases and contemporary classification can be linked in a meaningful way, it also highlights both the transient, contextual nature of some symptoms and the dynamic, fluid nature of eating disorders. This fluid dimension, I will argue, can paradoxically reverse, or at least qualify, a categorical affirmation of the modernity of bulimia - in its binge-purge form and as recognized in contemporary Western or Westernized contexts.

My argument is two-fold, in reference to a first distinction between core and contextual symptoms and a second one between full-blown and partial syndromes. Both distinctions are important in highlighting the ease with which contemporary taxonomic categories can be and have been, as a matter of fact, upset - in its sections on

taxonomy and epidemiology, Chapter I has often touched on this blurring of categories.

There is for instance the fact that while purging was not a criterion in the DSM-III classification, it gained access to the status of core symptom in the DSM-IV-TR (American Psychiatric Association, 2000) - the very symptom, which in its combination with bingeing defines the so-called modern syndrome. There is also the non-purging subtype of bulimia in the DSM-IV-TR, which seems to refer precisely to the unacknowledged past forms of the disorder. The frequent crossover from anorexia to bulimia as well as the open-ended symptom combinations allowed by the category of Eating disorders not otherwise specified offer yet other examples of muddled classification. In a more prospective way, there is no doubt that should amenorrhea⁴² no longer be considered a symptom of anorexia, on the ground that it automatically excludes males from the pool of diagnostic investigation, this would immediately have an effect on prevalence rates among men. In a more general way, occurrence rates would undoubtedly be impacted at many different levels if partial criteria were considered instead of full-fledged forms of pathologies. These few examples speak for a certain degree of fluidity that allows thinking of bulimia as interconnected with anorexia - a fluidity, which I think rules out a rigidly divergent historical course for each disorder.

The Interconnectedness of Anorexia and Bulimia around a Problematic of Control

In an apparent contradiction of interconnectedness, contemporary taxonomy, along with arguments of discontinuity in the case of bulimia and continuity in that of anorexia, seems to suggest a conceptualization of the two disorders as discrete categories. There is no doubt that such a conceptualization presents advantages. It enhances for instance tools of research by allowing clearer distinctions. It also has a major clinical impact - both in terms of identifying the purely physical ailments that result from each disorder and permitting the prescription of medication for their treatment [for instance osteoporosis, increased blood cholesterol, and loss of gray matter in the brain in anorexia; esophageal tear, enlargement of and tear in the stomach, and lung infection in bulimia (Keel, 2005)].

The approach I suggest is to a certain extent intermediary between perspectives that view anorexia and bulimia as discrete categories and those that assume they exist on a continuum. Indeed, without thinking in terms of a continuum that “flattens out a complex interacting set of issues and defences” (Shipton, 2004, 26), the overlap and fluidity in contemporary nosological categories do point out to what I set, following Shipton, as a working hypothesis: the interconnectedness of anorexia and bulimia as

“linked to a frightening, voracious appetite for the object”, with anorexic control a defense against bulimic desires and impulses (Shipton, 2004, 29). This hypothesis is

based on an object relation view inspired by Klein and Bion. Of course, it would be ludicrous, and probably anachronistic to try and find substantiation for such a symbolic meaning in the literature on historical precursors of eating disorders. However, it might be interesting to look at evidence from the past from the perspective of what Shipton describes as a constellation of common issues that lies under the surface of any eating disorder and centers on “themes of self-assertion, protest, defiance, spiritual superiority and self-realization (that) all crop up in explanations about anorexia in contemporary approaches” (Shipton, 2004, 14). Considering that introjective processes, which underlie impulses to incorporate the object, generate derivatives in the form of intrusion, it becomes possible to posit that phenomena of intrusion are implied in dynamics of anorexic control to defend against bulimic urges of incorporation. This allows extending the notion of control to intrusion, a first theoretical move in the articulation of the thesis that intrusion, as the overwhelming experience of invasion of receptivity, constitutes the fundamental psychological factor in the etiology of eating disorders.

A further step towards articulating the intrusion theory is provided in Chapter III in my other working hypothesis, which subsumes various eating disorders difficulties under the supremacy of intrusion through the proposition that intrusion aims at controlling objects and/or states and emotions. The psychodynamic proposition derives from Williams’ object relations model of eating disorders and its use of projective

identification (Chapter VI) to explain how, to avoid painful experiences of dependence and loss of the object, parts of the ego are forced in fantasy in the object in order to control it.

The function of eating and the body (ies)⁴³ it inevitably involves provide propitious primal arenas for struggles with need and desire in relation to the object - to curb it or release it; to control it or submit to it. At different times in history, in different social and cultural contexts, the object of desire may assume, through displacement and transference, different forms, but the dialectic of the self with the other - played out in the act of eating and involving symbolically and dynamically related control/intrusion issues - may ultimately be the same.

This is well illustrated in the enduring theme of rebellion against authority and the status of women as well as the burdens of womanhood, which anorexia seems to have conveyed across time from St Wilgefortis, St Margaret of Hungary, and St Catherine of Siena through to contemporary feminist and other interpretations of eating disorders in terms of a power struggle - in some sense, the feminine anorexic body as an arena where the sacred and the ‘feminist’ meet. In this context, I would like to evoke what could appear on the surface as a contradictory position and trajectory of bulimia and anorexia, and for which I suggest an alternative explanation around the issue of control.

43 See Chapter III on how eating disordered girls identify their body with their mother’s body.

I have mentioned earlier, in the context of the mass of evidence argument, an inherent difficulty to an open or public visibility of bulimic behaviors - they are not avowable, let alone idealizable, unlike anorexic comportments, which can carry sacred connotations, and therefore appeal to both subjects and their entourage. This is epitomized in the understandable absence in historical accounts on bulimia of any religious meaning of the phenomenon⁴⁴ - whether attributed by fasters themselves, their community, or observing/commenting lay and religious institutions. Unless mentioned in the context of self-starvation syndromes, and, with the exception of the recognition by the end of the 19^th century of a psychological component in both bulimia and anorexia, precursors of bulimia have in fact been described and explained mainly in terms of natural causes - physiological/medical and/or as curiosities. This fundamental difference in historical accounts on forerunners of anorexia and bulimia, which would support their status as discrete entities, can however be understood in an opposite way. If one accepts that anorexia and bulimia are dynamically interrelated, with anorexia in a way the antithesis of bulimia, one might recognize here the opposition between praiseworthy control and hard to confess lack of control, an opposition that underlies the respective anorexic and bulimic stands, and, further on, the “religious” as structure and the “non-religious” as

lack or loss of structure. In addition to a kind of horizontal continuity between anorexia and bulimia, a level of historical continuity in the former is then extended to the latter.

To conclude, answering the question of continuity in eating disorders is certainly difficult. Although this is true in particular in the case of bulimia, over which scholars are divided, it also applies to anorexia, which has triggered far less academic controversy.

The core and enduring symptom of self-starvation has been invoked to support the view of continuity in anorexia, while the association of bingeing with purging, which defines the modern syndrome of bulimia, has been deemed inconsistent, leading some to consider it as a modern Western disorder.

The complexity of the question arises from many directions. The inscription of any disease in historical and cultural contexts is an important element, bound to influence the expression of symptoms in specific yet transient ways. This makes the challenge of determining which symptom is core and stable and which is contextual and fleeting a complex task. This is further complicated by the danger of anachronism any retrospective assessment and classification entails, but also because of the blurring of categories that contemporary taxonomy reveals. Not only are symptoms fleeting, so are categories in successive manuals, and categories within manuals.

Insight into the meaning of eating disorders across time and space may nevertheless be possible if one posits the interconnectedness of anorexia and bulimia,

which the fluidity in categories allows, and considers their underlying mechanisms of restricting, engulfing and expelling as reflecting enduring dynamics of control that pertain to the object. In positing an overlap of control with intrusion on the grounds that intrusion aims to control objects and/or states of emotions (Chapter III), it becomes possible to invite intrusion in the equation of eating disorders. The overlap is substantiated in Chapter VII.

Before moving to the third part of this background survey, which will examine theories on the feminine specificity of eating disorders, I would like to make a final comment on one aspect of continuity that concerns the female/male ratio in these disorders in the past. The question is after all at the center of this work. In the absence of a systematic computation of gender distribution in historical accounts, not to mention the taxonomic challenge this would pose, it is impossible to confront the asymmetry in contemporary statistics on male/female prevalence rates with any tangible evidence from the past. Cautiously looking back at the non-comprehensive historical review above, and notwithstanding the well-documented phenomenon of holy anorexia among females in the late Middle Ages and early Renaissance, it does not however present a striking case for female preponderance in history. In this respect, it is worth mentioning Bordo’s (1993) reference to the little use of the concept of gender in Bruch’s (1973) landmark work on eating disorders in as late as the 1970’s. In fact, Shipton remarks that

Chernin (1985) was the first to point out that “the anorexic’s body was almost always a female body” (Shipton, 2004, 12). Although it is impossible to conclude on this issue, it is worth keeping this observation in mind when reflecting on the question of eating pathology in men.

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Chapter II has established a reasonable level of continuity between modern categories of anorexia and bulimia and historical syndromes of self-starvation and binging/purging - a continuity founded on enduring themes of control and on a

Chapter II has established a reasonable level of continuity between modern categories of anorexia and bulimia and historical syndromes of self-starvation and binging/purging - a continuity founded on enduring themes of control and on a