Anorexia Nervosa: Hilde Bruch and the Construction of Eating Disorders

In 1973, psychiatrist Hilde Bruch published Eating Disorders: Anorexia Nervosa, Obesity and the Person Within. The book, recognized as a “masterwork,” proposed a new conceptualization of eating disorders. Previously, eating disorders, alternately referred to as “feeding disorders” or “alimentary disorders,” had been loosely associated diagnoses primarily associated with babies and children. Bruch radically remade this category, defining “eating disorders” as the “misuse [of] the eating function” in an effort “to solve or camouflage problems of living that … appear otherwise insoluble.” ¹ Her book was immediately recognized as a game changer, solidifying her reputation as the key figure in this rapidly growing field. As a 1975 book review noted, her “name is practically synonymous with the title [i.e., “eating disorders”].²

Bruch’s book constituted a key turning point in the medical history of these illnesses. She defined anorexia nervosa and obesity as the core “eating disorders,” conceptualizing anorexia being the “grotesque mirror image” of obesity.³ This inspired one of her most radical ideas: that some people of “normal” weight suffered from the eating disorder of obesity. Arguing that they suffered severe personality disturbances despite “normal”-looking bodies, Bruch called them “thin fat people”; for many overweight people, she argued that weight loss was contraindicated and could, in fact, trigger severe mental illness. Bruch thus conceptualized eating disorders as a particular mode of disordered thinking rather than a kind of body or specific behavior.

My current research project, tentatively titled “Troubling Appetites: A Late-Twentieth-Century History of the Rise of Eating Disorders,” traces the transnational rise of eating disorders as a significant category of mental illness. Hilde Bruch played a key role in this story. Not only did she first articulate the understanding of eating disorders that is standard today; she was remarkably active and influential in the international psychiatric community, as well as being the first medical expert to write about eating disorders specifically for the lay public. Bruch’s role reached beyond simply serving as the field’s most prominent spokeswoman. Because of her seniority, international connections, and wide-ranging intellectual interests, Bruch was at the center of a new web of knowledge transfer that linked individuals—patients, doctors, and the general public—across space and time.

While historians of medicine have focused on the rise and fall of specific diagnoses, I focus instead on the construction of a category of illness. Eating disorders are an especially good topic for thinking about the production and dissemination of knowledge. First, because the diagnoses are recent constructs, it is possible to trace their emergence and circulation. Secondly, diagnoses of eating disorders dramatically increased at around the same time (the 1970s) in locations around the world, motivating a small group of widely dispersed experts to work together to conceptualize these new illnesses. Thirdly, eating disorders are unusual because of the remarkable popular interest that they have engendered, producing a remarkably rich and diverse pool of primary sources. In this blog post, I want to focus on a single individual, to suggest how one person can shape the construction of a medical field. Hilde Bruch’s significance was not solely due to the fact that she developed a new definition of eating disorders; just as important, her correspondence reveals the process by which medical and lay people circulated and absorbed this new knowledge, thus making it “real.”

The Construction of an Expert

Trained as a pediatrician in her native Germany before fleeing (she was Jewish) in 1934, Hilde Bruch began her career in the United States working on childhood obesity. By the 1960s her specialty had shifted toward anorexia nervosa, and she became a leading specialist in the then-obscure illness. Up to her death in 1984, Bruch remained an active member of the international eating disorder community. Her last book, Conversations with Anorexics, was published posthumously in 1984.

While Bruch had enjoyed an international reputation at least since the publication of Eating Disorders, it was her 1978 The Golden Cage: The Enigma of Anorexia Nervosa that transformed her into a minor celebrity. The first publication on anorexia nervosa aimed at a lay audience, it became an international best-seller. It is difficult to overstate the significance of The Golden Cage, which introduced the name and symptomology of anorexia nervosa to hundreds of thousands of people around the world.

In 1967, Bruch had written to a psychiatrist friend bemoaning the fact that “anorexia nervosa is such a rare condition that only a few psychiatrists have extensive experience with it.”⁴ Exactly a decade later, Bruch wrote to her frequent collaborator and close friend Italian psychiatrist Mara Selvini Palazzoli about the upcoming release of her newest book The Golden Cage. She had, she explained, decided to write “a down-to-earth book” because “there is a great deal of popular interest, and the mass media has got hold of anorexia as a describable illness.”⁵ The book’s success far exceeded anyone’s expectations. After the book’s publication, Bruch was interviewed by journalists, appeared on TV and radio shows, and was the subject of a feature article in People Magazine, where she declared that anorexia was “the hottest disease to have right now.”⁶ She fielded dozens of requests for interviews and feedback from novelists, filmmakers, and journalists interested in documenting this new and charismatic illness. This tremendous reaction gave Bruch, according to another letter to a fellow psychiatrist, “a feeling there will be a flood of autobiographical or family accounts of anorexia nervosa; I know of at least four or five.”⁷ She was, of course, entirely correct. Overnight, eating disorders, first anorexia but then also bulimia and binge eating, became a staple topic in young adult literature, literary memoirs, and celebrity gossip. 

Collaborative Narrations of a New Diagnosis

The Golden Cage not only taught people what anorexia was—it gave readers a specific language with which to describe and interpret the illness. Especially for readers with disordered eating, scores of whom self-diagnosed after reading the book, Bruch’s writing shaped their experience and understanding of the sickness. Her archive contains hundreds of letters attesting to her book’s influence in the late 1970s and 1980s. Indeed, the book created a new community for readers, enabling them to be part of a diagnostic but also social and emotional category of eating disordered people (made up, according to Bruch, of white, upper-class, intelligent young women).

In 1979, a “former anorectic” wrote that “while reading The Golden Cage, there were times I had to put the book down and just think about passages I’d read …. Often I felt ‘this was me’ and was surprised to see how the same feelings were felt by others.”⁸ An adolescent from Quebec City spent “the past year reading your two books Eating Disorders and The Golden Cage …. I think I have been very fortunate to learn about my illness by reading your books.”⁹ Similarly, a letter from Cologne, Germany, claimed that “it’s only for the reading of your book The Golden Cage that I know I am an anorexic.”¹⁰ Many letters articulated the ways in which the book circulated between patients, parents, and other lay communities; a Canadian teenager read the book because it was “referred to me by another anorexic girl,”¹¹, while a woman writing from her hospital ward claimed that “every anorexic in this hospital has ordered or is trying to find your book.”¹² A colleague in California told Bruch that “most parents [of her eating disordered patients] have already heard about the book and have inquired about it.”¹³

These quotes, selected almost at random from Bruch’s archive, attest to several things. First, they reveal how individuals—mostly adolescent girls and young women—learned to see themselves as “anorexic,” and thus as suffering from an eating disorder. They attest to the significance of diagnostic labels for seeking out treatment (many letter writers stated that they only sought treatment once they recognized that they matched the descriptions in Bruch’s books.) They also reflect how intimate and personal these textual relationships felt.

The idea that Bruch knew them because she described them permeates these letters. Bruch thus did not simply develop a diagnostic theory or challenge conventional wisdom; by teaching people what they had (an eating disorder) and what they were (anorexic), her writings, and the letters that they inspired, reveal the intimate relationship between reading, writing, and self-understanding that was central to the construction of the postwar field of eating disorders.

Finding Traces of Bruch in the Field of Eating Disorders

These letters are an especially moving illustration of the construction of eating disorders as a meaningful category of modern mental illness; however, Bruch’s archive exposes this process in many other ways as well. Bruch’s early work in anorexia and in psychiatric treatments for obesity meant that she established herself as an expert before most doctors had even heard of eating disorders. Her archive includes hundreds of letters dating back to the 1950s from doctors and patients from New Zealand to Saudi Arabia asking for advice and sharing observations. These constant requests compelled Bruch to serve as a sort of eating-disorders clearinghouse, and she worked tirelessly to connect desperate patients with a small but growing number of specialists. Bruch’s network was truly global; in 1980, for example, she wrote an Italian colleague in search of a Spanish-speaking therapist who could treat a Mexican anorexic who would be studying abroad in Florence.¹⁴ In another letter, Bruch gave the address of an Uruguayan colleague whom she had met at a conference in Copenhagen to the Peruvian mother of a young anorexic girl in search of specialists in South America.¹⁵ In 1977, in order to connect individuals with specialists, Bruch, with the support of the American Psychiatric Association, constructed a directory of experts and institutions with experience in treating eating disorders. This sort of project not only reflects the existence of a fully developed field of eating disorders; the act of assembling the directory constructed and reified the field itself. 

Bruch’s personality and lived experience also shaped the field in complex and subtle ways. The materiality of her own body is surprisingly present in her archive. She frequently referenced her childhood nickname “die Dicke” (the chubby one) when describing her early interest in overweight children. In private letters, she joked about how her own plumpness reflected her efficacy at treating anorexia. Her professional relationships were marked by real emotion—concern and love, but also dismissal and hatred. She tended to form deeply affectionate friendships with researchers whose work meshed with her own approach—often women psychiatrists working outside of major medical centers—and she openly criticized high-powered individuals whose work she disagreed with. She was especially vocal in her criticism of behavioral methods, which were advocated by most leading psychiatrists in the US and Great Britain. These authorities emphasized weight gain, usually achieved via “rewards and punishments,” as the necessary first, and sometimes only, component of treatment; Bruch insisted that long-term therapy targeting self-image and personality development was the only way to effect true change in an eating disordered patient.

Bruch’s identity as a Jewish refugee from Nazi Germany (she had lost most of her family in the Holocaust) shaped her career in complex ways as well, most obviously in her fraught professional relationship with West Germany.¹⁶ In an especially poignant example, Bruch engaged in an extended letter-writing campaign to tarnish the reputation of German psychiatrist Joachim-Ernst Meyer. Meyer was an up-and-coming researcher who was establishing himself as a German leader on anorexia nervosa and had falsely presented himself as a “resistance fighter” who had explicitly refused to align himself with Hitler and the Nazi Party. Bruch’s distress over this deception is evident in the multiple, heavily edited drafts of the letter that she wrote to Meyer. With the encouragement of several Jewish friends, Bruch wrote the editors of major psychiatric journals laying out Meyer’s wartime support of Hitler and his misrepresentation of his former political views, and she withdrew from a major international conference due to his participation. Meyer’s own career in Germany went on to be quite successful, but he remained little known outside of Germany; it seems plausible that Bruch played some role in this.

Hilde Bruch is widely recognized as one of the most important figures in the history of eating disorders, especially for her work on anorexia nervosa. I hope that this brief discussion of just a few of the thousands of letters contained in her archive has offered another way of thinking about her. I suggest that what was so significant about Bruch was not simply her insight into a specific diagnosis. Rather, her importance lay in her role in enabling the construction of a distinctive discourse on “eating disorders” that incorporated both the expert community and the wider public, a collaboration that was shaped by scientific dialogue, personal histories, friendships and animosities, and the emotions engendered by acts of both reading and writing.

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Alice Weinreb is an Associate Professor of History at Loyola University Chicago; her research interests include the history of the body, the geopolitics of food and hunger,  and the history of psychiatry.  She is currently working on a book tracing the late twentieth century rise of eating disorders, which has received funding from the National Endowment for the Humanities. She is also developing a digital database and constructing an archive documenting the postwar history of eating disorders.

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1. Hilde Bruch, Eating Disorders; Obesity, Anorexia Nervosa, and the Person Within (New York, 1973), 3.[↩]
2. “Review: Eating Disorders,” The Merrill-Palmer Quarterly 21 no. 3 (1973): 233.[↩]
3. Bruch, Eating Disorders, 3.[↩]
4. Hilde Bruch, M.D., papers (MS 007) (hereafter Bruch papers), Series VII Box 67, Folder 1; John P. McGovern Historical Collections and Research Center; Texas Medical Center Library; Houston, Texas.[↩]
5. Bruch papers, Series V Box 30, Folder 37.[↩]
6. Bruch papers, Series V Box 27, Folder 27.[↩]
7. Bruch papers, Series V Box 30, Folder 37.[↩]
8. Bruch papers, Series VII, Box 68, Folder 11.[↩]
9. Bruch papers, Series VII, Box 68, Folder 11.[↩]
10. Bruch papers, Series VII Box 68, Folder 13.[↩]
11. Bruch papers, Series VII, Box 68, Folder 11.[↩]
12. Bruch papers, Series VII Box 69, Folder 12.[↩]
13. Bruch papers, Series VII Box 3, Folder 43.[↩]
14. Bruch papers, Series VIII, Box 75, Folder 27.[↩]
15. Bruch papers, Series VIII, Box 69, Folder 18.[↩]
16. See Alice Weinreb, “Anorexia Nervosa and the Weight of the Holocaust,” forthcoming in Isis.[↩]

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