Food refusal and insanity: sitophobia and anorexia nervosa in Victorian asylums

Although anorexia nervosa emerged as a new syndrome in the second half of the 19th century, this clinical picture seemed to be unknown in the psychiatric hospitals or asylums. In asylum medicine, the commonly used concept of sitophobia to designate food refusal in the insane covered a wide variety of mental disturbances and cannot be plainly equated with anorexia nervosa. A major difference is the occurrence of hallucinations and delusions specifically centered around religion and digestion. Most probably, anorectic patients were not treated in asylums, but at home, in the doctor's office, or in general hospitals. This pattern may be partly attributed to the fact that both patients and doctors were focusing on symptoms of self-starvation like emaciation, constipation, and amenorrhea, which were primarily interpreted as referring to somatic diseases. Additionally, wealthy families probably preferred private care in water-cure establishments, sanatoria, and rest homes to the stigmatizing referral of their anorectic daughter to an asylum. Hence, the fact that late 19th-century institutionalized psychiatry was only incidentally confronted with anorexia nervosa may explain its lack of interest in the emerging syndrome.