Profiling Midlife Eating Disorders

Patients who present with eating disorders in midlife are often overlooked but do have some distinguishing characteristics, according to two clinicians from the Eating Disorders Center of Denver.

As Tamara Pryor, PhD and Kenneth L. Weiner, MD, reported at the recent National Eating Disorders Association Meeting in Baltimore, women who develop anorexia nervosa or bulimia nervosa in midlife may have experienced long-term struggles with body image, may have had an eating disorder earlier in life and have left treatment, and may have endured years of serious but not incapacitating symptoms. As some women age, they may feel challenged by loss of status in our youth-orientated culture, which may then lead them to develop an eating disorder.

‘The desperate housewife syndrome’

Dr. Pryor described receiving a phone call asking if anyone could speak to the phenomenon of the “desperate housewife syndrome.” She had never heard of this but when she searched on the Internet, she got more than 3,000 hits. Was this accurate or a media-driven phenomenon? She wondered.

As Dr. Pryor’s research continued, she learned that many women with an eating disorder first detected in midlife actually had a chronic course in which they had an eating disorder earlier in life, then a relapse. In other cases, a few middle-aged women developed an eating disorder after a critical illness, such as cancer or a brain tumor.

One significant difference between women who developed eating disorders early in adulthood and those who did so in midlife was that those with early-adult-onset eating disorders had higher novelty-seeking scores than did older adults. Both early-adult onset and midlife-onset eating disorder patients had higher-than-normal scores on harm avoidance measures. Persistence was slightly higher in young adults.

A classic case

Dr. Kenneth Weiner, Director of the Eating Disorder Treatment Center of Denver, described a classic case of an eating disorder uncovered in midlife. Dr. Weiner used a videotaped interview with a patient, a successful, well-educated middle-aged woman who nearly died of her eating disorder.

When he first encountered the patient, she was 52 years old, and in a coma in an intensive care unit. A diagnosis of end-stage anorexia nervosa had been made. Dr. Phil Mehler, of the Denver Treatment Center, questioned the diagnosis and asked the staff physician to look for an underlying infection. This turned out to be the case. The woman improved and began therapy for a long-term eating disorder.

Dr. Weiner told the audience that the woman actually had a chronic eating disorder that began 20 years before, when she went through a difficult divorce from a man who was 22 years older. During the marriage, she was always concerned about her appearance, and became even more threatened and competitive with younger women after her divorce. She began restricting her eating, but no one recognized the pattern until she was 38 years old and had lost a dramatic amount of weight.

When her family finally confronted her, she agreed to meet with an eating disorders therapist and seemingly went along with treatment. However, she related that although she lied during treatment and resisted treatment, no one confronted her because she was happily remarried, and ran a well-known and successful interior design business, and just seemed “slim.”

The woman later told Dr. Weiner that being a mature adult helped her deflect any comments about her disordered eating. On the surface it appeared that her life was completely in control; she even told people that she was naturally slim and that her father had been thin. The 5′ 5″ woman’s weight ranged between 80 and 90 lb, and she told Dr. Weiner that she spent time thinking about how she was going to be able to purge all through her life to stay thin.

Her physical state worsens

As a result of her eating disorder, she lost all her teeth at age 43, had multiple broken bones (no one questioned her low weight or bone status), underwent many severe illnesses, had a miscarriage and gradually went downhill physically.

Suggestions from the patient for family and physicians

What could have been done to intercept and successfully treat the eating disorder earlier? The patient related that because things seemed good on the surface, no one confronted her—”as an adult you could fend them off,” she said. In the videotaped interview with Dr. Weiner, the patient urged family and friends to persist, mustering all the effort possible to help, and to remember that “Your loved one is suffering a life of hell, secrecy, and self-loathing.” Don’t let it go, she urged, and instead suggested a serious search for professional help.

She also noted that if therapists had been more confrontational with her and had involved her second husband in therapy (he was never involved in her treatment), the outcome might have been better.

Overlooking the superficial

Dr. Weiner added that the patient was such a functional anorexic that no one persisted in her treatment—superficially all seemed well. Instead, he advised therapists to carefully look at the data, to take a very detailed, long history to see what previous interventions were made, and to talk with other providers because it is not unusual for people to end up in multiple treatment centers. It’s important to look at what has happened, what broke down in recovery, what were the precipitating events, and what were the physical ailments, he said.

Dr. Weiner also stressed the importance of working with the patient’s family to get a clear picture. The history you get is often state-related rather than trait-related, he said. “Patients will often give you a state-related history—do not accept this at face value,” Dr. Weiner said. He added, “We aren’t used to seeing a middle-aged woman or man, particularly an accomplished adult, develop an eating disorder in midlife.”

He urged the audience to remember that eating disorders don’t just affect the young: “If it looks like an eating disorder, it may well be one,” Dr. Weiner said.