Clinical Child Psychology and Psychiatry

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'Anorexia Nervosa' Still Relevant in the Twenty-first Century? A Review of William Gull's Anorexia Nervosa
Sloane Madden Clin Child Psychol Psychiatry 2004 9: 149 DOI: 10.1177/1359104504039178 The online version of this article can be found at: http://ccp.sagepub.com/content/9/1/149

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TEST OF TIME Anorexia Nervosa Still Relevant in the Twenty-rst Century? A Review of William Gulls Anorexia Nervosa
SLOANE MADDEN
Childrens Hospital at Westmead, Australia

A B S T R AC T In 1874 William Gull published Anorexia Nervosa an article detailing the cases of two young women presenting with severe and unexplained weight loss, as well as a more general exploration of the authors experience with the condition he labelled anorexia nervosa. The article represents a fascinating rst step in the study of a disorder of ever-increasing focus both in medicine and among the general population. Gulls original description still forms the basis of modern day denitions of anorexia. To read Anorexia Nervosa is to add depth and history to our understanding of eating disorders. It also reminds us of an earlier era when medicine and psychiatry were not so separated as they are today.

Introduction
E AT I N G D I S O R D E R S A F F E C T

an estimated 3% of young women with nearly twice this number having signicant eating problems that do not reach diagnostic thresholds (Becker, Grinspoon, Klibnski, & Herzhog, 1999; Walsh & Devlin, 1998). Eating disorders most commonly develop during adolescence and early adulthood, and are the third most common chronic disorder in this age group (Beaumont, Russell, & Touyz, 1993). Eating disorders are a major source of morbidity and mortality with between 5 and 10% of individuals with anorexia nervosa dying every decade, a rate of death nearly

C O N TA C T : Sloane Madden, Department of Psychological Medicine, The Childrens Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail: sloanem@chw.edu.au.

Clinical Child Psychology and Psychiatry 13591045 (200401)9:1 Copyright 2004 SAGE Publications (London, Thousand Oaks and New Delhi) Vol. 9(1): 149154; DOI: 10.1177/1359104504039178 www.sagepublications.com 149

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12 times higher than in similar aged young women (Becker et al., 1999). Although often thought to be a phenomenon of the late twentieth century, descriptions of anorexia nervosa have existed throughout history. William Gulls article Anorexia Nervosa is famous, not only because its name is synonymous with eating disorders, but also as it is one of the rst clear descriptions of the eating disorders that recognized the importance of psychological factors in the illness.

William Gull
Sir William Withey Gull was born in 1816 in Colchester, the son of a barge owner. He studied at Guys Hospital, graduating in medicine from the University of London. Gull was among the pre-eminent physicians of his time, rising to prominence after successfully treating the Prince of Wales for typhus, for which he was rewarded by being made a Baronet in 1872 before becoming the personal physician to Queen Victoria. Gull was famous not only for his description of eating disorders, but also for recognizing the link between myxoedema and withering of the thyroid gland (Enersen, 2002). Although the description of anorexia nervosa was rst made by the English physician Richard Morton in 1689, it was Gull and the French physician Jean Lesegue in the 1870s who independently rst described the clinical entity of anorexia nervosa as we understand it today (Goldbloom, 1997). Gulls article Anorexia Nervosa published in 1874 not only highlighted many of the clinical features of anorexia nervosa, but also lent its name to the condition.

Anorexia nervosa
William Gulls article was published in 1874 in Transactions of the Clinical Society of London. It is an article of around 1500 words drawing from an address Gull delivered at Oxford in 1868. It describes the cases of two young women presenting to Gull with severe and unexplained weight loss, as well as a more general exploration of the authors experience with the condition he labelled anorexia nervosa. Although such an article would hardly be given prime place in modern medical journals driven by the dictums of evidence-based medicine and randomized controlled trials, it represents a fascinating rst step in the study of a disorder of ever-increasing focus both in medicine and also among the general population. Gulls article is concise and clear, providing an accurate description of the condition we still refer to as anorexia nervosa. The two cases described by Gull would be very familiar to clinicians working with eating disorders. It is important, however, to focus on both Gulls clinical descriptions and his discussions regarding treatment and aetiology. The lack of wordiness makes these discussions easy to miss and for this reason much is gained from reading the article more than once.

Anorexia nervosa and the modern context

So what is the relevance of William Gulls article to the current understanding and treatment of eating disorders? Does it still have something to offer apart from historical interest? To answer such questions it is interesting to review Gulls article using the headings common to textbook descriptions of anorexia: denition, history, epidemiology, aetiology, clinical features, course and prognosis, and treatment.

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What is anorexia nervosa?

Current denitions or descriptions of anorexia nervosa are dominated by those proposed by DSM-IV (American Psychiatric Association, 1994) and ICD-10 (World Health Organization, 1993). Central to these descriptions are the refusal to maintain or gain weight above a minimal developmentally normal level, intense fear of weight gain or becoming fat, a severe disturbance of body image and underlying hormonal abnormalities, in particular amenorrhoea. In Gulls description of anorexia nervosa he emphasizes the physical symptoms of his patients while acknowledging their psychological origins. Gull emphasizes his two patients severe emaciation and amenorrhoea although does not describe the abnormal body image, fear of weight gain and fat phobia common to current denitions of eating disorder. Although Gull does not overtly describe a refusal to gain or maintain a developmentally appropriate weight in his patients, he does underline the refusal of his patients to co-operate with treatment: The inclination of the patient must be in no way consulted. Do these apparent omissions on Gulls part represent a lack of psychological sophistication and observation or were these features which are considered central to modern presentations of eating disorder not present? In his article published in the Archives Gnrales de Mdecine in April 1873, Dr Earnest Charles Lasgue emphasized the active psychological disgust for food that led to weight loss in his patients (Garnkel, Kaplan, & Saddock, 1995). Again he did not describe the abnormal body image and fear of fatness. In a brief scientic article presented by Gerald Russell (2002) it was argued that abnormal body image, weight phobia and fear of fatness, described since the 1960s by Bruch, Crisp, and Russell respectively, are modern day phenomena, conned to cultures dominated by the cult of thinness. Such assertions are supported by research by Lee, Ho, and Hsu (1993) who noted the absence of fat phobia in over 50% of Chinese anorexic patients in Hong Kong. In this context, Gulls description of anorexia nervosa may be seen as a description of the core symptoms of anorexia nervosa proposed recently by Russell (2002) of weight loss and treatment non-compliance. This discussion has major implications for categories such as Eating Disorder not Otherwise Specied.

Anorexia, the size of the problem

William Gulls article is a case description so it is perhaps a little unfair to review what it has to say about the epidemiology of eating disorders. Despite this, Gulls views on sex and age distribution seem remarkably accurate. The subjects of this affection are mostly of the female sex, and chiey between the ages of 16 and 23. I have occasionally seen it in males at the same age.

The causes of anorexia nervosa

Gull saw anorexia nervosa as a diagnosis of exclusion proved by the absence of lesions from the pulmonary and abdominal organs, a condition of simple starvation due to a morbid mental state. Gulls view of anorexia as a central rather than peripheral disease process differentiated him from his peers who saw anorexia as a disorder of the gastrointestinal system or a form of tuberculosis. As he pointed out: the importance of diagnosing such cases in practice is obvious; otherwise prognosis will be erroneous, and treatment misdirected.
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Although Gull rightly identied the importance of psychological factors in anorexia nervosa he does not go beyond this. Since Gulls article numerous theories have been put forward to explain anorexia nervosa, psychological, social and biological. Currently, genes and serotonergic mechanisms dominate biological thinking, while the role of the media and its portrayal of beauty is a constant in social theories of eating disorders. Psychological theories have stressed control and sexuality, while developmental models have stressed the importance of family factors in the disorder. Although Gull can hardly be blamed for missing many of these factors, his lack of discussion of the psychosocial backgrounds of his patients leaves many questions unanswered.

Anorexia and the family

In an almost throw away comment at the very end of his article Gull describes families as being generally the worst attendants. No more is said or further explanation given about this. Given the ongoing controversy regarding the role of the family in the genesis and course of anorexia Gulls lack of explanation is frustrating. While many would share Gulls feelings regarding families, it is important to note that family-based therapy of young patients with short histories of anorexia is one of the few clearly demonstrated benecial and effective treatments for anorexia (Russell, Szmukler, Dare, & Eisler, 1987). In addition, poor family functioning is seen as one of the predictors of poor outcome. When these issues are taken into account it becomes clear that the involvement of the family is vital in any treatment strategy. What Gull noted was the potential for negative interactions between the family and the patient without looking for the reasons why.

The clinical features of anorexia nervosa

It is in the clinical descriptions of anorexia nervosa that Gull article excels. Gull notes not only the emaciation of his two patients, but also their lack of menstrual periods, slowed pulse and breathing and low temperature. Not only did Gull note these critical clinical features but he also linked them to refeeding regimes and mortality associated with anorexia. One of the other prominent features of the disorder Gull noted was the motor restlessness and compulsive exercising associated with the disorder. As he noted: the restless activity referred to is also to be controlled, but this is often difcult. Finally, he notes intermittent bingeing by his rst patient who experienced occasional periods of voracious appetite.

Anorexia nervosa, the long-term outcome

As regards prognosis, none of these cases, however exhausted, are really hopeless whilst life exists; and, for the most part, the prognosis may be considered favourable. Gulls description of the long-term outcome of anorexia nervosa may at rst seem overly optimistic in a disorder characterized by chronicity and high levels of mortality though it seems to t well with recent studies. Although certain individuals with anorexia nervosa will recover after their initial presentation, the average length of illness is felt to be between 5 and 6 years (Katzman et al., 2000). Despite the prolonged nature of the disorder, in excess of three-quarters of individuals with anorexia achieve full recovery (Katzman et al., 2000) with fewer than 30% developing symptoms of bulimia nervosa during the course of their illness. Similarly, studies of this group have found that nearly
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three-quarters of children have good levels of psychosocial functioning despite high rates of depression and anxiety. Mortality rates in anorexia nervosa remain controversial with gures ranging from 5 to 22% with deaths occurring as a result of suicide or malnutrition (Neiderman, 2000). Gulls view of prognosis must also be placed against the high morbidity and mortality at the time.

The treatment of anorexia nervosa

Gulls article offers us no mention of psychological interventions or treatments, although this is not unexpected given the limited discussion of psychological factors in the article. Despite this there are some important and practical insights offered into the physical treatments of the disorder that are still relevant today. Food should be administered at intervals varying inversely with exhaustion and emaciation. In the context of the potentially lethal refeeding syndrome, Gulls recommendations seem ahead of the time remaining both appropriate and relevant to current practice. Further, Gulls recognition of the dangers of letting the starvation-process go on t with modern practices of aggressive nutritional rehabilitation to minimize the serious and potentially irreversible physical consequences of malnutrition. Neuroimaging research has shown irreversible changes in the temporal lobe region of the brains of individuals with anorexia nervosa (Lambe, Katzman, Mikulis, Kennedy, & Zipursky, 1997), while loss in bone density due to anorexia is often proving irreversible (Treasure & Serpell, 2001).

Conclusion
That much of William Gulls article remains relevant today is a testament to his observational and clinical skills. Its strength lies in its concise and clear clinical descriptions of anorexia nervosa and its recognition of the importance of psychological factors in its genesis, course and prognosis. It is ironic that Gull saw distinguishing anorexia nervosa from similar physical maladies as important due to its much more positive prognosis, rather the reverse of current views of the illness. The weakness of Gulls article is its lack of exploration of the psychological characteristics of the disorder. Although Gull acknowledges the psychological origins of anorexia nervosa there is only a limited description of the patients mental state and no thought given to psychological interventions in its treatment. Anorexia Nervosa does not contain information that cannot be found in modern psychiatry and psychology texts, though to consider it in these terms is to overlook its enormous historical impact on current concepts of eating disorders. While many psychological theories explaining the aetiology of eating disorders have come and gone, Gulls original description still forms the basis of modern day denitions of anorexia. Its clarity, brevity and common sense also serve as a model to the observation, classication and treatment of new medical syndromes or disorders. To read Anorexia Nervosa is to add depth and history to our understanding of eating disorders. It also reminds us of an earlier era when medicine and psychiatry were not so separated as they are today.

References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Press.
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