Eating Disorders in Men and Women in Later Years
Contributed Article by Dr. Kimberli McCallum of McCallum Place
Women and men in their 30s, 40s and 50s are now seeking treatment centers for eating disorders in increasing numbers, challenging beliefs that eating disorders occur mostly in adolescent girls. Although the prevalence of eating disorders in middle age is not known, there seems an increase not only among those suffering but also in professionals and family members more likely to consider the diagnosis and treatment whatever the age.
Older adults are not all alike in their presentation. Patients may present with new onset symptoms, re-emergence of symptoms, increased awareness and distress associated with persistent low grade symptoms or enduring and severe symptoms. Those with chronic or intermittent symptoms, never treated for an eating disorder, may finally seek care because they find themselves in a health crisis precipitated by many years of disordered eating behavior.
Older patients may present with the whole gamut of symptoms including compulsive exercise, rigid eating, vomiting or laxative use, extreme body dissatisfaction, preoccupation with plastic surgery, restrictive eating, binge eating, low weight, obesity or extreme weight fluctuations. Co morbid psychiatric and medical conditions are common as they are in youth, particularly struggles with alcohol, anxiety and depression.
It is important to remember that not all those seeking treatment later in life have struggled with severe or enduring symptoms throughout life. Many have been able to build careers, families and have had periods of relative wellness with partial or full remission of symptoms. If not entrenched in their symptoms or when the symptoms recur in the context of a role transition, emotional maturity and confidence associated with age and experience may facilitate psychotherapy and recovery. Our capacity for empathy and charity and our ability to self regulate typically increase as we age. We are more able to shift our outlook towards big picture thinking, away from focus on appearance and control. These changes are associated with maturing brain function. Growing awareness and acceptance of one’s own mortality may engender courage to face our fears. Patients stuck in rigid eating patterns and rigid strategies of managing distress around weight and shape eating are stuck in immature modes of interacting, attempting to avoid inevitable change, pain and uncertainty that we all must face as we live an engaged life. Themes inaccessible in youth are often ripe in mid and later adulthood.
Little is known about late onset of eating disorders in men. In our experience, older men are increasingly seeking treatment particularly for concerns about body fitness, struggling with binge eating and compulsive exercise.
Late life can also pose its own developmental challenges, straining one’s capacity to adapt. Pregnancy can have a complicated effect on women who have struggled with eating and body dissatisfaction. Weight gain and body changes may intensify body image concerns. Happily, many show remission or symptom reduction during pregnancy.
Consideration of the babies needs may be enough to override fears about weight gain and nudge those who had been ambivalent to commit to eat for the sake of their unborn baby. Post delivery body image concerns often resurface. Parents naturally are reminded of their own adolescent transition as their children mature and separate. Old conflict and unhappy memories may emerge.
Marital conflicts become evident as couples again spend more time together as adult children leave home. Divorce is typically associated with extreme stress. Old maladaptive habits of coping may resurface. Middle age is also a time when many are faced with aging and illness of their own parents. Shifting from adult child to caregiver for their own parents, unresolved hurts and frustrations can trigger old behaviors. Many years of imbalance may have taken a toll on their bodies precipitating regret, limitations or even disabilities. In today’s economy, middle aged adults may face job loss or change, financial stress.
The death of a parent can overwhelm ones’ capacity to adapt leading to relapse, especially in patients with fragile coping styles and limited supports. Vulnerable individuals can become deskilled, reaching for old ways of regulating emotion. Grief and loss may complicate to depression. Therapy strategies may be adjusted to also address domains related to aging, life transitions, and loss.
Special considerations are in order for patients who have struggled with severe and enduring symptoms of an eating disorder. Reducing social isolation and harm prevention are significant concerns. Chronic malnutrition can damage self regulatory systems and alter brain function leading to extreme rigidity. Gastrointestinal function may be irreversibly damaged by laxatives, poor tissue perfusion and nutritional insufficiency leading to motility and absorption problems.
Osteopenia and osteoporosis may limit mobility earlier than expected. Patients with chronic illness will struggle with a sense of loss, as they become aware of missed opportunities and experience regret and shame about any perceived lack of commitment to treatment in the past. The therapist may be faced with mourning of opportunities permanently lost as patients find themselves without careers, spouses or fulfilling relationships, unable to fulfill or pursue their dreams due to chronic debilitating symptoms.
There are no clinical trials comparing eating disorder treatment strategies in older patients. Adaptation of treatment as usual to address the special needs of older patients presenting with eating disorders seems appropriate. In our experience, new onset or re-emergence of symptoms in older patients may be successfully treated by restoring nutrition, strengthening supports, and psychotherapy strategies similar to those helpful in younger patients.
Patients who have been actively ill for over a decade may benefit from a different focus with special attention to improving relationships, maintaining productivity and harm prevention. As in other patients with severe and enduring mental illness, the general principles of building on strengths, including spouse family or friends in treatment, and comprehensive ongoing assessment and treatment of medical co and psychiatric morbidity are extremely important.
Research focusing on treatment of eating disorders in mid-life is crucial. Only then will we reasonably be able to develop reliable strategies to improve life satisfaction and decrease suffering, morbidity and mortality associated with these illnesses when they present or persist into later life.
Published Date: October 1, 2009
Last Updated and Reviewed By: Jacquelyn Ekern, MS, LPC on 8/8/14
Published on EatingDisorderHope.com, Eating Disorder Resources