Adult Anorexia

Alice, age 62, remembers that her battle with anorexia started soon after the birth of her first and only child. “I really don’t know life without it,” she says. Sara, age 42 and the mother of three children, weeps as she remembers her long struggle with anorexia in high school and college and finds it hard to believe that she has, once again, developed a disorder that she knows inflicts such suffering in her life.

A Growing Population for Eating Disorders

By Jan F. Sherbak, PSY.D.

Carol, 52, says, “Soon after my divorce, I started eliminating certain foods from my diet in an effort to lose weight; then it just became an obsession to eat less and less. Everyone told me how good I looked, and I liked hearing it. But now, I can’t stop it. I’m afraid to eat. I’m afraid to gain weight. I just can’t make myself eat.”

While the typical image of an anorexic is that of a young, overachieving female, there are increasing numbers of adults developing this disease at a later age or struggling with it in their adult years.

Historically, less than 5 percent of patients who sought treatment for anorexia nervosa were women over the age of 40. Today it is believed that more than 10 percent of individuals with anorexia are 40 years or older. While anorexia has been reported in elderly patients in their 70s and 80s, these are generally women who have suffered with the illness for 40 or 50 years.

Although the fundamental causes of anorexia nervosa remain elusive, there is growing evidence that interacting sociocultural and biological factors, as well as various personality traits, contribute to its cause.

When considering adult anorexia, case reports and the general clinical consensus suggest that body image issues and eating disorders are increasing as the baby boomer generation grows older. As is often the case, adverse life events, such as empty nesting resulting in a loss of identity, marital crisis or divorce, death of a spouse, or perimenopausal symptoms, have been found to trigger these older-onset syndromes. The fear of aging has also been described as a major precipitating factor in some patients; this fear is compounded by our culture’s constant exposure to images of television and movie actresses who remain overly thin as they age.

Some studies also suggest that the war on obesity may actually be promoting eating disorders by emphasizing body hatred and creating an obsession with controlling food intake.

In Jane Fonda’s autobiography, she details her struggle with an eating disorder well into her 40s. “My food addiction has represented a misguided search for perfection and nurture to fill the emptiness,” she says. Fonda’s expression represents what appears to be a “new norm” in our culture, where women who are 35 years and older believe they must be beautiful, thin and perfect, and that somehow achieving thinness will fulfill unmet emotional needs.

Anorexia nervosa can be diagnosed by a treating physician or psychologist. The American Psychiatric Association’s Diagnostic and Statistical Manual defines the disorder as a refusal to maintain normal body weight, characterized by the following:

• Rapid loss of at least 15 percent of ideal body weight, with no physical illness.

• Intense, irrational fear of gaining weight or becoming fat.

• Perceptual distortion of body weight or shape.

• Amenorrhea (loss of menstrual cycle).

There are two main subtypes of anorexia nervosa: restricting and binge-eating/purging. It is worth noting that some people affected by this disorder can fluctuate between these subtypes. The restricting subtype typically involves weight loss that is accomplished primarily by dieting, fasting or excessive exercise. The binge-eating/purging subtype typically involves binge eating and/or purging through self-induced vomiting or the misuse of laxatives, diuretics or enemas.

The devastating effects of anorexia are pervasive in the lives of affected individuals. Early in the course of their illness, patients often have limited recognition of the disorder and experience their symptoms predominantly as intrusive repetitive thoughts; sometimes there is a corresponding limited recognition of the disorder by patients’ families. Depression, anxiety and obsessional symptoms soon emerge. Rigid cognitive styles develop and perfectionistic traits begin to take form. Social isolation is common, and a lack of interest in sex is often present among patients with the restricting type of anorexia nervosa. Patients with anorexia nervosa of the binge eating/purging subtype may also be suicidal and engage in self-harming behaviors.

In the psychodynamic literature, patients with anorexia have been described as having difficulties with separation and autonomy (often manifested as enmeshed relationships with parents or others), emotional regulation (including the direct expression of anger and aggression), and difficulty negotiating psychosexual development. These skill deficits may make women who are predisposed to anorexia nervosa more vulnerable to cultural pressures for achieving a stereotypic body image.

The physical effects of anorexia include heart, brain or kidney damage, loss of reproductive ability, severe bone loss, and nutritional disorders (anemia, brittle hair and nails, cold sensitivity). The disorder has the highest mortality rate of any emotional disorder and claims the life of more than 10 percent of those who develop the disorder. This mortality rate is about 12 times higher than the annual death rate due to all causes of death among females ages 15 to 24 in the general population.

Estimates of the incidence or prevalence of eating disorders vary, depending on the sampling and assessment methods. There are still many gaps in our current knowledge base regarding this illness. According to the National Institute of Mental Health, an estimated .5 percent to 3.7 percent of females will suffer from anorexia in their lifetime. Only an estimated 5 percent to 15 percent of individuals with anorexia or bulimia are male, although there continues to be a significant rise in eating disorders among males, as well.

The hopeful news is that complete recovery from an eating disorder is possible, says Dr. Anita Johnston, clinical consultant for Focus Healthcare in Chattanooga and clinical director at the Ai Pono Eating Disorder Program in Honolulu, Hawaii. “The recovery process itself becomes a path to greater awareness,” says Dr. Johnston, who is also the author of the book Eating by the Light of the Moon. “The skills that are learned along the way will serve (those suffering with an eating disorder) the rest of their lives, long after the eating disorder has cleared.”

According to Dr. Johnston, there are three critical skills learned through recovery: body awareness, emotional literacy and assertive communication. “Assertiveness is so critical,” she says. “I have never seen anyone fully recover from any kind of disordered eating without developing that skill.”

Dr. Johnston also emphasizes how important it is for young girls to develop “emotional literacy,” learning to express their emotions, in order to stave off issues with eating disorders.

There are several physicians and therapists in the Chattanooga area who include eating disorders as a subspecialty in their practices. Solace Eating Disorder Clinic, located on South Broad Street, offers intensive outpatient treatment. For more information, visit solaceeatingdisorderclinic.com.

Focus Healthcare of Tennessee, located on Shallowford Road, specializes in residential treatment for women eighteen and older, suffering from anorexia, bulimia, binge eating and associated disorders. For more information visit www.FocusCenterForEatingDisorders.com.

There are four levels of treatment for anorexia, all of which involve a multi-disciplinary, collaborative approach that focuses on recovery of both psychological and physiological issues. Initially, a team of specialists is developed as part of a treatment plan, comprised of a psychologist or therapist, a primary care physician and/or psychopharmacologist, and a nutritionist.

Outpatient treatment involves psychological and nutritional therapies, no less than once per week, with routine monitoring by a medical professional.

Intensive outpatient treatment involves eight or more hours of group therapy, at least two days per week; this is often a preferred approach to treatment because it can provide the intensity needed to address these disorders without compromising an individual’s work, school or family responsibilities.

If an individual is severely medically compromised, admission to a medical facility is often recommended. This can provide a patient with critical care, including nutritional refeeding and medical stabilization, before any other type of treatment is started.

Residential treatment, the highest level of care, requires that an individual relocate to a facility that focuses on the treatment of these disorders. These facilities provide intensive therapies that are multi-modal and include 24-hour monitoring of weight, food and behaviors. Typical stays for this type of treatment are 60 to 90 days.

Chattanooga is fortunate to have nonprofit resources in the area that provide education and assistance for families affected by eating disorders. The MCR Foundation, a local organization that was created by the family and friends of a young woman who died in 2005 from complications of an eating disorder, provides resources for people affected by eating disorders in the Chattanooga area (www.mcrfoundation.com). Additionally, the Eating Disorders Coalition of Tennessee is a nonprofit educational resource for Tennesseans who are seeking assistance and support for eating disorders (www.edct.net).

The first step in treating an eating disorder is seeking help, for either yourself or someone you love. Professionals in the area are well-equipped to help guide patients and their families toward treatment and recovery from this debilitating illness.

Dr. Jan Sherbak is a clinical psychologist and certified eating disorder specialist. She works in private practice treating adolescents and adults struggling with various psychological disorders or life transitional issues, including, but not limited to, eating disorders. She is co-owner of Solace, LLC, an intensive outpatient eating disorder clinic, located in Chattanooga.