The term anorexia gives rise to a number of misunderstandings. In today’s psychiatric language, “anorexia nervosa,” or simply anorexia, refers to a disorder characterized by the pursuit of thinness as a source of harm and unhappiness, resulting from a rigid and absolute identification of low weight and a thin appearance as an aesthetic ideal or measure of personal worth, and of higher weight as a danger and a condition to be avoided. The disorder is classified among “eating disorders,” together with bulimia, although this classification itself creates a certain degree of confusion in terms and concepts.
First of all, bulimia and anorexia do not constitute two completely separate entities. They are, in part, two phases of the same history of an eating disorder: anorexia-bulimia, or overweight-anorexia-bulimia. Bulimia itself was defined by Russell as a complicated variant of anorexia. Both disorders share a preoccupation with controlling food intake and with body weight and shape, with apparently opposite but often alternating or coexisting situations: the ability to maintain fasting or increase caloric expenditure in order to sustain thinness, or episodes of binge eating. Bulimia itself, in one of its two subtypes (with or without compensatory behaviors), shares with anorexia the use of compensatory behaviors—ways of neutralizing food intake or its caloric equivalent—which include vomiting, purging, or methods that are not actually relevant but are nevertheless believed to help reduce weight, such as diuretics or prolonged physical exercise.
The term anorexia, however, has also been used with other meanings. In itself, the word simply means “absence of appetite” or “reduction in food intake, up to complete fasting,” without specifying the possible reasons. Thus, when a person does not eat or refuses to eat, the symptom can technically be described as “anorexia,” but this does not necessarily have anything to do with the anorexia nervosa described above.
Indeed, the “hysterical anorexia” described by Lasègue in 1873 was what today would be defined as a somatoform disorder or panic disorder, or would correspond to a depressive episode with anxious symptoms. The person, typically a woman, “first experiences a disturbance after eating // neither she nor those around her attribute any lasting discomfort to it // the following day the same sensation occurs again // and the patient becomes convinced that the best remedy for this undefined disturbance is to reduce her food intake”; she “gradually reduces food, sometimes on the pretext of a headache, sometimes out of fear that the painful sensations following meals will occur // after a few weeks this is no longer a passing aversion: it is a refusal of food that will continue indefinitely // the illness is fully established and will follow its course inevitably.”
This description still corresponds remarkably well to clinical pictures of somatoform disorders otherwise referred to as “irritable bowel syndrome” or hypochondria, as well as to more severe forms involving bodily delusions. In particular, there are forms that combine, as occurs in various cases of irritable bowel syndrome, the idea of having something wrong with one’s digestion with an anxious relationship to food, leading to the selection of foods considered “safe” and the exclusion of others that, from time to time, are regarded as responsible for the symptoms.
The person is generally convinced, to varying degrees, that their symptoms are caused by food or, in any case, by the reaction to food, and therefore that the solution must be dietary. The consequence is often more or less rapid weight loss, accompanied by an attitude of rejecting criticism or suggestions that the problem may be psychiatric in nature. Attention becomes focused on the body.
The interpretation of these conditions as “hysterical” assumed that behind this attitude one should look for a conflict, repressed anger, or unresolved pain. More simply, one might say that people with these disorders often already have a personality characterized by a need for control, a search for balance or fear of losing it, and heightened attention to environmental and bodily signals, together with a tendency to form personal beliefs to which they become attached, regarding them as useful or, in any case, not open to criticism.
The formal diagnoses associated with these forms of weight loss due to reduced food intake also include depressive disorders or preliminary phases of classical depression. In advanced stages, the person may begin to develop a genuine bodily delusion, leading to erroneous beliefs about how their organs function, and to actual hallucinations concerning the weight, position, movements, or condition of their organs and tissues: an enormous abdomen, an immobile intestine, a constricted stomach, a blocked or closed intestine, colitis, hypersensitive mucous membranes, bubbles of air moving around or becoming trapped, and so forth.
Thus, in severe forms, the process moves from simple bodily sensations or impressions to delusion—that is, an absolute, self-generated conviction.
What is absent from this syndrome is concern about the adequacy of one’s physical appearance and the effort to lose weight. If anything, it is true that a person who becomes increasingly focused on bodily functions gradually becomes less spontaneous and less interested in social relationships, partly because mealtimes and drinking are avoided or experienced with discomfort, and becomes less interested in the pleasurable aspects of life, particularly when mood is depressed.
These are therefore not forms of anorexia driven by concern about thinness. Rather, the central concern is the perceived dangerousness of food or the supposed fragility of the digestive system.
When Lasègue spoke of a “fatal course,” he did not mean that the condition was necessarily lethal. Rather, he meant that once the condition persisted for a certain period, it tended to worsen in its mental component, of which the intestinal and eating symptoms were an integral part. These were not intestinal disorders as such, but rather statements, perceptions, fears, or ultimately convictions concerning the body.
The majority of these conditions, particularly painful irritable bowel syndrome, hypochondria, and panic disorder, can be treated without excessive difficulty. Intervention is more difficult during a depressive phase involving a delusional idea, or in a longstanding somatoform disorder, in which the person “defends” their eating habits, having spent years rejecting criticism or alternative proposals and becoming increasingly convinced that their beliefs about their particular bodily functions are correct.
With regard to these forms of anorexia that are not related to concerns about physical beauty or adequacy, reference should therefore be made to the texts in the sections on anxiety or somatoform disorders and depression.