Midlife eating disorders
Midlife eating disorders are being increasingly discussed both in the research literature, amongst clinicians, and in the popular press. Today, the New York Times ran a piece on the subject that raised many of the issues facing both sufferers and clinicians.
Most clinicians are in agreement that they are seeing more and more older women with eating disorders. I don't doubt this, although it should be said that we don't have hard data on whether that means more older women are suffering from eating disorders or that more older women are presenting for treatment. Several treatment centers (including the Cambridge ED Center and Renfrew) have programming specifically geared towards older women and addressing the issues specific to this age group. Which is a really good thing as many of the practical, day-to-day coping needs of adolescents and older women are probably going to be different.
A study comparing female inpatients aged 40+ and those aged 18-25 found that the older women showed
"significantly more diagnoses of anorexia nervosa, both subtypes, and fewer diagnoses of bulimia nervosa; greater ED severity but fewer body image issues and less body image distortion; greater emotional and behavioral overcontrol and symptom denial; more bipolar and major depressive disorders, suicidality, and sexual abuse histories; a trend toward greater misuse of calming/sedating substances; and fewer maturation issues."
The real question is: why the uptick? Why is it that more and more older women are being diagnosed with eating disorders? Could it be improved awareness, that starving, bingeing and purging aren't just "teen things"? That people are talking about it now? Could we be seeing an uptick from several decades ago and they have relapsed or never recovered?
For women in their 40s and over (which the Times article seemed to focus on) who seek treatment for an eating disorder, there are essentially three scenarios: the ED began in midlife, the woman has been chronically ill since adolescence/young adulthood, and the woman had previously recovered from an ED but has since relapsed. Research suggests that the first scenario is pretty uncommon, as one study found no evidence for midlife-onset EDs, though it did survey a small number of women. Other studies, however, have looked at women reporting midlife onset and found that women whose ED began after age 40 were more likely to be anorexic, and showed higher symptoms of denial.
Clinical anecdote, however, does seem to indicate that EDs in most midlife women began in adolescence and young adulthood. This goes along with the NEDA statistic that 86% of ED sufferers report illness onset prior to age 20. No one knows exactly why most EDs are triggered in adolescence, but changes in both hormones and social milieu seem to combine in a very bad way. Another factor is that, in modern, Western culture, almost no woman can pass the age of 20 without having gone on a diet, gotten a stomach bug, or otherwise eating poorly for a period of time. It's pretty darn hard. I had spoken with Harriet Brown during her search for women whose EDs began after 25, and she said she really couldn't find anyone who didn't at least have a sub-clinical disorder in adolescence.
I have much sympathy for the struggle to maintain recovery throughout a lifetime--it's something I'm currently striving for, if occasionally sucking at. Relapse happens. It's a grim reality, and midlife does bring on a host of new stresses that can cause a person to deliberately or inadvertently alter their eating habits.
I have just as much sympathy and empathy for those who have struggled constantly since adolescence. I have a little less sympathy for our long, gloried history of ineffective treatments, but I still wonder. The NYT article said that "the recent surge in older women at eating disorder clinics is not a reflection of failed treatment, experts say, but rather a signal that these disorders may crop up at any age."
It's true that EDs can crop up at any age, but the evidence doesn't support that this is true for the vast majority of midlife eating disorders. Most of them have roots in adolescence. And I can't help but wonder whether we would be seeing these numbers if there were effective treatments around 20 years ago.
13 comments:
As someone at midlife I've forgiven my body and am grateful it gets out of bed in the morning. So it registered with me that older woman seeking treatment exhibit "...greater emotional and behavioral overcontrol and symptom denial; more bipolar and major depressive disorders, suicidality, and sexual abuse histories; a trend toward greater misuse of calming/sedating substances; and fewer maturation issues."
I think the uptick in this age range is either chronic non-disgnosed disorder or an onset brought about by new diet consciousness - suddenly we are faced with cholesterol and heart conditions, diabetes, etc that require a change in diet that is often not explained well - combined with life stress of aging parents, loss of parents, tuition bills, medical bills, uncertain job security, etc and you have the cascade of triggers that will effect persons already so inclined. Add in the "omg, you have wrinkles and arm flaps you must immediately join a gym and pretend to be 25 again!!!" nonsense and viola! Over the top.
A med fellow I knew a few years ago told me about anorexia among geriatric patients. They don't want to gain and become a burden. They are living on fixed incomes and can't afford much. They've been told to eat a low sodium diet and don't know what to eat anymore as everything has sodium in it. Misinformation and lack of real nutritional counseling are main contributors at this age.
I don't believe in the "not the result of failed treatment" assertion. Nor do I believe the genesis of these womens' illnesses truly began in midlife. There may have been treatment avoidance; clinician and patient denial or minimizing; sub-clinical status that was never explored; other health or mental health issues that superceded the eating disorder; and/or a functional chronicity, especially when loved ones are used to seeing a person underweight or area accustomed to disordered/behavioral habits that the situation is normalized. It *is* a treatment failure, inasmuch that the clinical-care system has failed to identify or refer these patients ... or compel them to treatment prior to midlife. Additionally, I was in "recovery"/remission for seven years, but that improvement didn't come as a result of an earlier hospitalization (which failed) but was something I achieved by myself without even outpatient support ... years after formal intervention. As well, the formal treatment I have had since relapse hasn't been a failure, per se ... I have made progress in various areas only to continue to struggle in others. It is a persistent, complex, multidimensional illness with vulnerability points through the lifespan ... I think it would be more accurate to categorize the eating disorder as a different illness/phase of illness during different stages of life. It looks one way in teens; behaves another, perhaps, in early adulthood; and looks different yet at midlife and beyond into geriatric populations. The demographics and circumstances of those stages also have a lot to tell about how an ED patient presents, what compels a patient/family to seek help, and the nature of effective treatment.
I hate dealing with this. I'm in "midlife" too. I've had an eating disorder for almost 20 years and disordered eating for years before that. I was binging for years. Now I'm less than 1/2 of what I was and can't stop lossing. I've been in thearpy about three months and was ready to "take a break". Not because I needed a break but because I can't face eating all the things they want me to eat. Thinking of what I used to eat vs what I will eat now it's just nuts. I think if I can just skip out for a few week's I can get down another 10 to 20 lbs or so. Of course then I'll need to loose another 20 the next week. Sorry for the downer post I'm just not in a good place right now. I ate like 170 calories for breakfast and then had 5 almonds when I got to work and I feel like I gained 5 lbs. This thing is an illness that want's to hurt me. And most of the time I will allow it to do so. Everyone here is eating sausage egg and cheese McMuffins and I feel like I'm gaining weight just smelling them. I've never purged before but just want to go and purge right now. Sorry for the post I'm just trying to hold it together.
I read the article too, and one thing hit me: the author commented on the importance of "eating healthy" to recover. I think this is a problematic view- although I do not speak from personal experience, I've read enough, including this blog, to know that recover requires EATING, period, and a lot, and that "eating healthy" is not a helpful focus. But it's thrown at us ad nauseum, day in and day out, in every newspaper, on tV, radio... The funny thing is that the "eat healthy" (and for god's sake can't ANYONE use the proper term healthFULLY?- sorry I digeress) has annoyed the hell out of me to the point that I have my own personal backlash and will often go eat a donut or some potato chips when I've heard or read too much. It's the contrarian child in me that never quite grew up.
Marie
I am almost 40 and eating disordered - but I have been so since I was 13 and went on my first diet. It's come and gone over the years. The past few months of my life have been excruciatingly stressful - so what is my first response? "Well if I just lose weight and get myself under control everything else will follow", of course. And I feel so stupid, like, this is something for teenage girls to be doing, I know it doesn't work, it never has before, so why am I doing this to myself AGAIN? But I suppose logic has nothing to do with it.
And then there are some of us that are in-between. I'm 28...and more recently started to have problems. I was a tiny child and puberty made me "curvy"...never overweight, but my goal was always to be thin. I tried all sorts of diets, then became vegan and finally was a bit closer to what I wanted. It was when I started exercising and restricting calories that I really started to loose a lot...combine that with the stresses of being an adult (supposedly)...there you go.
So, maybe I had signs of an eating disorder all along, but I don't remember it that way. I remember always been worried about my weight, giving up for a period of time (hey, I'll just be curvy forever), but I don't ever remember THIS.
Anyway, thanks for discussing this article...it's very interesting!
this is exactly like the book "lying in weight".
I wonder if it's a jump off from that. Good book by the way. I recommend it.
Thank you ALL for your feedback and sharing your honest experiences.
Anon mom,
You're right- I do think treatments for EDs have been historically ineffective. I do want to make sure I distinguish between treatment providers (who may have not had any better tools to work with then "we'll wait until you're ready to eat") and the actual treatments themselves.
And EDs can wax and wane in severity. Intense stress and (oddly) very little stress tend to set me off into ED behaviors. Mild amounts of stress have usually translated into motivations for recovery rather than going back to the ED.
I'm 28 and so in that in-between age as well. I don't have the same issues as college students as I have managed to live successfully on my own and prepare my own meals, etc, even if it was short-lived. I have ED-related independence issues (in that I can't yet plan and prepare my own food effectively), but otherwise, I'm okay. Yet I don't have a husband and/or a family, either. It would be interesting to see more research on this age in particular (singles aged 25-40) and maybe some targeted therapy groups or treatments.
Tianne,
I enjoyed parts of "Lying in Weight," and I admire and respect Trisha Gura very much. That being said, although the book addressed an important topic, I didn't think it looked at EDs in light of the most recent science and understanding of EDs as a biologically-based illness.
Thanks for posting this. ED's are being seen as not just a teenage disorder anymore. I am not sure that I have an eating disorder but whatever it is that I do have is certainly not normal. I can't tell you how many times I've thought to myself-I'm too old for this. I feel ridiculous with my concern over being skinny when as an adult there are so many other things to worry about in the world. It's nice to know that there are others out there that feel the same.
CeCe,
Even though I'm still in my 20s (though barely!), I do understand what you mean when you say you feel too old to be obsessed with being skinny. It has helped me to think of this obsession as a symptom of an actual illness rather than a vain desire that continues to stalk me. Because outside of the ED, I don't really care about size and shape to a large degree. I care about health and moving my body and such, but not the size of my thighs.
As far as I know, Cambridge Eating Disorder Center does not have special programming for older women. Their residential is split, but the age division is (generally) 16-20 and then 20 on up. Partial they attempt to split similarly, but this depends on what their demographics are like. I think IOP is also theoretically supposed to be split between adolescent and adult but in practice this almost never happens. I'm in my early 20s and have been in groups at all levels of care there with teenagers and 50+-year-old women alike.
I wonder how many of these midlife ED patients were post-partum when they became symptomatic. More and more women are having babies in their late 30's and early 40's. Having a baby is very stressful both physically and emotionally. Plus there's such pressure now on new moms to "bounce back" quickly. Forget the old "9 months on, 9 months off". Now the bar has been set by Heidi Klum modeling lingerie mere weeks after giving birth to her 2nd child.
The times in my life where I've come closest to relapsing have been after the birth of my 3 kids.
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