It's commonly assumed that anorexia nervosa is a recent phenomenon in teenage girls, caused by over-exposure to images of stick-thin actresses and models. One striking aspect of Hungry Hell, which combines autobiography with a survey of developing knowledge of the condition and its treatment, is Kate Chisholm's assertion that self-starvation in girls is not new.
Citing examples from as early as the 17th century ("At first it flatters and deceives the Patient, for which reason it happens for the most part that the Physician is consulted too late," wrote one doctor in 1694; the philosopher Thomas Hobbes met a girl who had allegedly taken nil by mouth for six months apart from "a feather dipt in water") she shows that the disease, its symptoms and distinct phases were the same then as now - even when society viewed voluptuousness as the feminine ideal. What is shocking, in Chisholm's view, is that we know so little about it after so long.
So if image-consciousness and a perceived failure to conform to some fashionable norm can't fully account for the phenomenon, what can? It's not as simple as wanting to be thin; the term "slimmer's disease" is misleading. Anorectics don't starve themselves to be beautiful, but often to curb the development of their maturing bodies and to repress the desires that accompany adolescence. "Perhaps puberty and all the confusion that comes with it creates in some teenagers an existential burden. What's the point of all this business of eating and defecating if it only brings death at the end of it?" Having become dangerously anorectic in her twenties, the author, now 49, takes us through the stages of decline and recovery from an insider's position. In the 1970s, the condition was hardly known; but when as a student in Edinburgh she heard of a girl who had become emaciated, Chisholm recognised something of her own attitudes. Now, she wonders if she deliberately "chose" anorexia, and acknowledges that a series of misgivings and feelings of inadequacy led to her decline. She fitted the anorectic "type": "hypersensitive, perfectionist, fearful and yet also fiercely driven by the need to prove myself". After various treatments, she began her recovery during a delayed winter train journey: cold, helpless, tearful, inadequate, she became angry with herself for the first time.
Charles Lasegue, treating patients at a Paris hospital in the 1860s and 70s, wrote: "Woe to the physician who, misunderstanding the peril, treats as a fancy without object or duration an obstinacy which he hopes to vanquish by medicines, friendly advice, or by the still more defective resource, intimidation." Rather than hand over responsibility for the sufferer's eating to nurses or use a system of rewards and punishments geared to meeting weight targets, current policy involves patients charting their own progress, and provides a range of activities so that meals are not the sole focus of each day. But provision for dietary disorders is inconsistent; the UK has 39 specialist units, but uneven distribution means that half our health authorities have no clinics or units at all. The care of anorectics is often undertaken by parents and family, who face the frustration of being rebuffed at every attempt to help. Sympathetic to the demands she imposed on her own family, Chisholm likens the situation to warfare.
Hungry Hell is a short, readable and engaging book, combining the author's personal insights with wide-ranging references and viewpoints - from Naomi Wolf and Susie Orbach to Simone Weil and Joan Smith. It is well worth reading, especially for those in contact with adolescents. Chisholm refers to female patients, but does remind us that boys too can suffer. I was surprised to learn that one male sufferer who has written eloquently about his experiences is the garden writer and TV presenter Monty Don.