ART AND IMAGES IN PSYCHIATRY and Anorexia Mirabilis Miss K. R— and St

James C. Harris, MD

The want of appetite is, I believe, due to a morbid mental state…. I prefer…the more general term [anorexia] “nervosa,” since the dis- ease occurs in males as well as females, and is probably rather cen- tral than peripheral. Sir William Gull, 18741(p310,311)

I say it to you in the sight of God, that in every possible way I could I always forced myself once or twice a day to take food; and I pray to God…that he will grace me in this matter of eating so I may live like other creatures, if this is his will.… St Catherine of Siena, 1373-13742(p25)

In the autumn of 1868, Sir William Gull provided the first modern description of a severe . In a lecture at the University of Oxford, in Oxford, England, he described “a peculiar form of disease occurring mostly in young women, and characterized by extreme emaciation.”1(p305) Six years later, he proposed the name anorexia nervosa in his seminal publication “Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica).”1 Gull provided 3 detailed case descriptions with woodblock illustrations based on photographs of the young women and discussed their outcomes. He noted that 1 case had a fatal termination. Despite this case, he wrote that none of the cases are hopeless as long as life exists. The final case that Gull described was that of Miss K. R— (Figure 1), a patient that he saw in consultation with another physician; hers was the most severe presentation. Gull noted that this case was so extreme that he had her photographed Miss K. R—. Photograph for woodcut engraving by C. S. Ticehurst. Courtesy of and accurately engraved for publication to make clear the Christine Ruggere, Department of the History of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland. severity of her illness. Fortunately, she responded to refeed- ing and, within 6 months, was “nearly well.” Seeking to trace the history of anorexia nervosa, some phy- The best-known contemporary portrayal of Catherine of sicians have retrospectively diagnosed the conditions of fe- Siena is a fresco (http://www.basilicacateriniana.com/storia male medieval saints as anorexia nervosa because these saints _en.htm) by Andrea di Vanni, one of her many disciples. The would abstain from eating food to such an extent that, in some fresco shows a gaunt St Catherine with a young female devo- instances, they died.2-4 Virtuous self-abnegation and tee kissing her hand. It was placed on one of the pillars in the have been referred to as “holy anorexia,”3 or anorexia mirabilis,4 Capella delle Volte (Chapel of the Veils), where Catherine which is similar to anorexia nervosa with regard to the physi- prayed, in the church of San Domenico in Siena. ology of and its focus on seeking perfection and pu- Catherine (Caterina) Benincasa was born in Siena in rity. However, it is in many ways distinct from anorexia ner- 1347. When she was 6 years old, she is reported to have seen vosa and occurred in an entirely different sociocultural context. Christ in pontifical vestments above her neighborhood St Catherine of Siena, a patron saint of Italy, is the most Dominican church. A year later, she made a vow of perpetual prominent of the “holy anorexics.”3 She was a model of virtue, virginity. As a young girl, Catherine was familiar with fasting and her excessive fasting was widely emulated. The Floren- because she had observed her older sister’s food refusal as tine baroque Italian painter Carlo Dolci illustrated the ascetic protest against her husband’s misbehavior. When Catherine piety of St Catherine of Siena (Figure 2).5 She is shown in the was 15 years old, her older sister died in childbirth, and her habit of a Dominican tertiary with a crown of thorns. This paint- parents sought to have Catherine marry her sister’s widower. ing refers to her vision in which Christ offered her the choice of Catherine’s response was to fast in protest, and she did not a crown of gold or a crown of thorns. She chose the latter. marry.

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problems caused by its placing so much emphasis on fasting as evidence of saintliness. The Church responded with guide- lines for fasting that no longer emphasized holy fasting in de- cisions about beatification but, instead, focused on good works. People with anorexia nervosa usually starve themselves from fear of fatness. The disorder is associated with a dis- torted view of body image. In contrast, anorexia mirabilis was coupled with other ascetic and penitential practices, such as lifelong virginity, wearing hair shirts, and sleeping on beds of thorns, and the belief that gluttony was sinful. Rather than mis- diagnosed anorexia, it may have been a legitimate form of self-expression.4 Still, despite their motives, some of these women may have been genetically vulnerable to the disorder and thus developed anorexia nervosa. Anorexia mirabilis largely disappeared during the Renaissance. By then, ex- treme fasting was seen by church officials as heretical, socially dangerous, and sometimes considered Satanically inspired. Severe self-starvation in modern times persists as anorexia nervosa. Current researchers seek to understand its neurobiology.7,8 Two neural network mechanisms are pro- posed that involve limbic brain affective modulatory func- tions. A top-down circuit centered on the subcallosal cingu- late and a bottom-up circuit involving the insula are proposed.7 The insula cortex is part of a distinct neural network that is in- volved with regulating energy balance.8 It is the brain region Carlo Dolci (1616-1686), Italian. St Catherine of Siena. Oil on panel, 24.4 × 18.1 cm. © Dulwich Picture Gallery, London, England/Bridgeman Images. linked to the affect of disgust. The insula is central to intero- ceptive self-awareness and is important in the regulation of autonomic, sensory, and affective stimuli. It has been linked Later, Catherine, after seeing a vision of St Dominic, joined to features of illness that involve body image and food restric- the Dominican order. There she declared a mystic marriage to tion. A better understanding of neural circuitry may facilitate Christ and, soon afterward, began her mission. Catherine was new treatment strategies for this perplexing disorder. unique in living as nun in the community and not in a con- 1. Gull WW. Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica) (1874). vent. She lived in isolation in her parents’ home. Catherine was In: Acland TD, ed. A Collection of the Published Writings of William Withey Gull. a peacemaker and played a critical role in the return of the London, England: New Sydenham Society; 1894:305-314. papacy from Avignon, France, to Rome, Italy.6 She occupies 2. Vandereycken W, Van Deth R. From Fasting Saints to Anorexic Girls: The History of Self-Starvation. New York, NY: New York University Press; 1994. a major place in the history of Italian religious literature. Al- 3. Bell RM. Holy Anorexia. Chicago, IL: University of Chicago Press; 1987. though illiterate, she left more than 375 letters that she dic- tated to her disciples. In the months before her final depar- 4. Bynum CW. Holy Feast and Holy Fast: The Religious Significance of Food to Medieval Women. Berkeley, CA: University of California Press; 1987. ture for Rome, where she died at the age of 33 years, she 5. Luongo FT. The Saintly Politics of Catherine of Siena. Ithaca, NY: Cornell composed her book: The Dialogue of Divine Providence, which University Press; 2006. is said to have been dictated while in ecstasy. Despite being 6. Imorde J. Carlo Dolci and the aesthetics of sweetness. Getty Res J. 2014;6:1- very actively involved in religious matters, for her adult life, 12. doi:10.1086/675787. her diet was limited to water and vegetables. Self-starvation 7. Lipsman N, Woodside DB, Lozano AM. Neurocircuitry of limbic dysfunction is believed to have been a contributing factor in her death. Cath- in anorexia nervosa [published online March 12, 2014]. Cortex. doi:10.1016/j erine said that her refusal to eat food was an affliction. Still, .cortex.2014.02.020. she would eat at times to prove that she was not possessed by 8. Frank S, Kullmann S, Veit R. Food related processes in the insular cortex. Front Hum Neurosci. 2013;7:499. a demon that told her not to eat. Although she reported stom- ach pains after eating, she was always able to receive the Host in Holy Communion. Author Affiliation: Department of Psychiatry and Behavioral Sciences, Like Catherine, religious medieval women claimed to ab- Developmental Neuropsychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland. stain from all types of food with the exception of the Eucha- Corresponding Author: James C. Harris, MD, Department of Psychiatry and rist, which was taken to signify their devotion and the strength Behavioral Sciences, Johns Hopkins University School of Medicine, 1800 of the spirit. With regard to popular opinion, it seemed not to Orleans St, Baltimore, MD 21287 ([email protected]). matter that reported periods of fasting for religious women Section Editor: James C. Harris, MD. 2 were impossibly long, said to be months to many years. This Conflict of Interest Disclosures: None reported. proclaimed long duration simply added to the allure and won- Additional Contributions: Appreciation is expressed to Angela Guarda, MD, der for believers. The soon recognized the director of the Johns Hopkins Eating Disorders Program.

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