The Scary Rise In Adult Eating Disorders

 Susan was 43

Usually she just had a cup or two of plain pasta. Sometimes, as a treat, a diet soda. But whatever she ate or drank, Susan* kept it to around 500 calories a day. A year passed, and anytime she tried to eat more, her stomach would clench until she vomited. Her skin turned blotchy, her eyes became sunken, her hair started falling out. Yet, she felt numb.

Susan had overcome a turbulent upbringing, married a great guy, and set up house in a small, idyllic Pacific Northwest town. Life was good, until two years ago, when her out-of-control, alcoholic father ended up in the hospital. Once again, his crises cast a dark shadow on her life, and Susan's old emotional demons returned. Her insides twisted every time the phone rang, would it be the doctor? the police?, and little by little, the constant drama of dealing with her dad squelched her normally healthy appetite.

By June 2011, the 5'4" Susan had lost over 40 pounds and weighed in at less than 100.

She found excuses not to join her family at the dinner table, focusing instead on privately planning out every morsel that went into her mouth. Her husband grew frantic until, finally, Susan went to a doctor, who was at a loss. He ruled out a series of gastrointestinal conditions, then said, "And you're too old for anorexia.".

Eating disorders leaped into the national conscience in the 1970s and '80s, when the number of diagnosed cases exploded. The patients were adolescent girls, many of whom became anorexic or bulimic as a means of controlling their bodies, and, by extension, their lives, as they made their way through puberty. So many girls fell victim that eating disorders were branded a teenage disease. (And experts continue to see a troubling number of cases among teen girls, says Ovidio Bermudez, M.D., board member of the National Eating Disorders Association.)

Yet lately doctors have noticed a disturbing spike among a different group: women in their late twenties, thirties, and forties. At the Renfrew Center's 11 treatment locations, the number of patients over age 35 has skyrocketed 42 percent in the past decade. Likewise, a couple of years ago at the Eating Recovery Center in Denver, an estimated 10 percent of patients were over age 25; today, a whopping 46 percent are over 30. And when it opened in 2003, the University of North Carolina's Eating Disorders Program was designed for adolescents, now half of its patients are over 30 years old.

Just like their younger counterparts, adult eating disorders deliver a mind-body punch that kills more people than any other mental illness. Patients of all ages can suffer impaired brain function, infertility, dental decay, or even kidney failure or cardiac arrest. But while the teen and adult diseases share physical symptoms, and both can be tied to deep psychological roots, their catalysts are quite different, says psychotherapist Jessica LeRoy, of the Center for the Psychology of Women in Los Angeles. "As women get older and their lives evolve, so do their stressors and triggers," she says. These can nudge the door open for an eating disorder. But research on the adult-onset versions is lacking, and without sufficient tools and awareness, women like Susan are being misdiagnosed.

When her physician failed to pinpoint a cause, Susan and her husband sought several more opinions about her ever-shrinking size. The other doctors also ignored the possibility of an eating disorder, though one did suggest she seek psychiatric care. Susan went back home, where she lived in fear and confusion, her health rapidly deteriorating. Finally, a friend whose teenage daughter was anorexic recognized her symptoms and urged the family to consult an eating disorder specialist. After two years of starving herself, Susan checked into a clinic, where she needed to be hooked up to a feeding tube to survive.

On any given day, nearly 40 percent of American women are on a diet. The weight-worry gun is loaded early: By the time they reach age 10, 8o percent of girls fret that they're fat. Their main "thinspiration," according to experts: the ultra-slim starlets glorified in popular culture.

It seems unlikely, though, that women who make it into adulthood with healthy eating habits would suddenly become swayed by such images. "Grown women used to be allowed to have curves," says LeRoy. "As they got older, their bodies were supposed to change, especially after having kids." But times have changed. The emergence of the MILF meme has spawned a novel form of pressure for an older age-group. And though LeRoy point outs that appearing svelte post-pregnancy isn't a bad thing, "the problem is when mothers try to turn back the clock and look like they're 18 by starving themselves."

Of course, celeb scapegoats are not the only cultural influence at play. Ironically, a growing national impetus on super-healthy living might be fueling some adult eating disorders, says Emmett Bishop, M.D., director of adult services at the Eating Recovery Center in Denver. While the message itself (smart food choices, reduced portion sizes, ample exercise) is justified, and necessary in fighting America's obesity epidemic, "some women who are prone to eating disorders might take that message and run too far with it," says Bishop, using it to validate food restriction or as an excuse not to eat at all.

Particularly at risk are women with extreme personalities (i.e., those who lean toward all-or-nothing behavior), says eating disorder nutritionist Sondra Kronberg, R.D., director of the Eating Disorder Treatment Collaborative in New York. "When a woman like this hears that red meat has a higher fat content, she might really hear 'All meat is bad and loaded with fat; I can't eat it,'" she explains. And cutting out entire food groups can snowball into a full-fledged disorder.

 

New Eating Disorders

Anorexia and bulimia aren't the only dangerous eating behaviors

 

For decades, the eating disorder lexicon had two main entries: anorexia and bulimia. But modern research reveals that these fall woefully short of encompassing the many facets of disordered eating. In the early '90s, the American Psychiatric Association introduced a new diagnostic category: eating disorders not otherwise specified (EDNOS). A catch-all label that includes dozens of subdiagnoses, EDNOS applies to patients who don't meet the exact criteria for anorexia or bulimia but still have very troubled relationships with food or distorted body images. Today, EDNOS diagnoses significantly outnumber anorexia and bulimia cases. "The atypical has become the typical," says Ovidio Bermudez, M.D. These define just a few atypical eating disorders.

 

Orthorexia

A fixation with healthy or righteous eating

 

Orthorexics often eat only organic foods, eliminate entire food groups, or refuse to eat anything that isn't "pure" in quality, says clinical psychologist Sari Shepphird, Ph.D. Unlike anorexics, they don't necessarily think they're fat or strive to be thin; some are motivated by a fear of bad health, a fixation with complete control, or the desire to improve their own self-esteem. Ironically, severe orthorexia can lead to malnourishment.

 

Pregorexia

Extreme dieting and exercising while pregnant to avoid gaining the 25 to 35 pounds of weight doctors usually recommend

 

"There's more social pressure on women to look thin during and after pregnancy," says Shepphird. "But pregorexia comes with very serious health problems." Starving moms-to-be are at risk for depression, anemia, and hypertension, while their malnourished babies are often miscarried or born with birth defects.

 

Binge Eating

Compulsive overeating, often to deal with negative emotions or stress

 

Binge eaters consume large amounts of food very quickly—until they're uncomfortably full. Most sufferers eat in secret to hide their habits. Many feel powerless to stop eating and are disgusted with themselves afterward; but unlike with bulimia, they don't attempt to reverse a binge by vomiting or fasting. While not all patients are overweight, obesity—and its related health problems—are obviously a risk.

 

"As early as age 30, many women hit a point at which they feel there are certain things they should have accomplished," says Kronberg. "They evaluate their lives, and if they see a void, they look for something that will make them feel good." In essence, a perceived lack of success can morph into a feeling of failure and become an eating disorder catalyst. But emerging research shows that yet another factor could turn an innocent desire for self-improvement into an unstoppable compulsion.

 

Anorexia Athletica

An addiction to exercise

 

Sufferers work out well beyond the requirements for good health, often to the point that their gym time interferes with their job or relationships. "Instead of throwing up, so-called compulsive exercisers purge calories by working out religiously," says Shepphird. "Often, if they don't keep up with their rigorous routine, they feel tremendous anxiety or guilt." They're also at risk for potentially fatal cardiac problems and depression.

 

Drunkorexia

Restricting food intake in order to reserve those calories for alcohol and binge drinking

 

A University of Missouri study found that almost 30 percent of female college students exhibit drunkorexic behavior, "saving" their calories for booze in order to avoid gaining weight or to get drunk faster. Bad idea: These women are upping their chances for alcohol poisoning, uninhibited sexual behavior, and long-term consequences like heart and liver diseases.

part 2

Risk Factors

Environmental, social, biological, and psychological factors all contribute to eating-disorder risk. Early childhood environment and parenting may have a substantial impact. Many sufferers report dysfunctional family histories, with parents who were either emotionally absent or overly involved in their upbringing. As a result, these children may not tolerate stress well, they may have low self-esteem, and they may have difficulty in interpersonal relationships. Children who have been abused either physically, sexually, or psychologically are also highly vulnerable to eating disorders, particularly bulimia. Those raised by eating-disordered parents may be at heightened risk due to repeated exposure to maladaptive food-related behaviors.


Professions, activities, and dietary regimens that emphasize food or thinness may also encourage eating disorders. For example, athletes, ballet dancers, models, actors, diabetics, vegetarians, and food industry and nutrition professionals may have higher rates of disordered eating than the general population. In addition to environmental and social influences, biological and psychological factors may also increase risk for eating disorders in some people. Low levels of serotonin, a neurotransmitter involved in appetite regulation and satiety, may be indicative of a predisposition to pathological eating behaviors. Similarly, as many as 50 to 75 percent of those who are diagnosed with eating disorders suffer from depression, a mental illness also associated with abnormalities in serotonin balance. Other psychiatric disturbances, such as bipolar depression, obsessive-compulsive disorder, seasonal affective disorder, post-traumatic stress disorder, attention-deficit–hyperactivity disorder, and addictive behaviors, are also common in people with eating disorders.

Causes

Societal influences also contribute to this illness. Increasingly, Westernized culture portrays thinness as a coveted physical ideal associated with happiness, vitality, and well-being, while obesity is perceived as unhealthy and unattractive. This has encouraged a growing sentiment of body dissatisfaction, particularly among young women. Endless images of unrealistically thin models and actors in all forms of media further promote body dissatisfaction—one of the strongest risk factors for the development of disordered eating.


Abnormal eating patterns are most likely to develop during the mid- to late teens, a period of considerable physical, psychological, and social change. While the exact events that lead to the evolution of these disorders are unknown, there are two common milestones that can trigger disordered eating, especially in those with a biological predisposition. The first is the occurrence of a traumatic event, such as the death of a loved one or a divorce. The other is the adoption of a strict diet, which may be even more pivotal than a personal trauma. In fact, rigorous dieting has been identified again and again as the most common initiating factor in the establishment of an uncontrollable pattern of disordered eating.

Treatment Modalities

Treatment is based on a combination of psychotherapy, medication, and nutritional counseling. Goals include restoration of healthy body weight, correction of medical complications, adoption of healthful eating habits and treatment of maladaptive food-related thought processes, treatment of coexisting psychiatric conditions, and prevention of relapse. Depending on the severity of the illness, therapy may be conducted on an outpatient, day treatment, or inpatient basis.

DiagnosisAnorexia nervosa.Bulimia nervosa.Binge eating disorder.Eating disorder not otherwise specified.PrevalenceRisk FactorsCausesTreatment ModalitiesOutpatient therapy.Day treatment programs.Inpatient hospitalization.Medication.OutcomesBibliographyInternet Resources

Outpatient therapy.

Outpatient therapy provided by practitioners specializing in eating disorders is appropriate for highly motivated patients within 20 percent of their normal body weight and whose illness is mild or just developing. Treatment consists of cognitive-behavioral therapy, intensive nutritional counseling, support-group referrals, and medical monitoring. At the outset of treatment, a contract is established, outlining an anticipated rate of weight gain (usually between 0.5 and 2 pounds per week), target goal weight, and consequences if weight gain is not achieved. Vitamin and mineral supplementation and the use of liquid supplements to facilitate weight gain may also be indicated.

Day treatment programs.

Day treatment programs are being used with increasing frequency in place of inpatient hospitalization. This form of therapy provides an intermediate level of care for patients who require frequent monitoring but do not require treatment twenty-four hours a day. It may be used for patients who are not responding to outpatient therapy or who are stepping down from inpatient hospitalization. Treatment, which may take place four or five days per week from morning until evening, is similar in structure to outpatient therapy, but is provided on a more intensive level.

Inpatient hospitalization.

Inpatient hospitalization is indicated for patients whose eating disorder has reached life-threatening status. Criteria for admission to such programs are weight loss of 25 percent or more of ideal body weight or the presence of an eating disorder in a child or adolescent. It may also be necessary for individuals who are medically unstable. Usually, participants in inpatient programs are anorexic, although hospitalization for bulimia may be necessary if there is serious deterioration of vital signs, uncontrollable vomiting, or concurrent psychiatric illness.


The immediate goals of inpatient treatment are weight gain and stabilization of vital signs. In many cases, the patient is so fragile that complete bed rest is required. Eating is gently encouraged. In extreme medical situations refusal may be met with tube feeding or, in rare instances, intravenously.

Medication.

Medication is increasingly becoming a routine part of treatment for eating disorders. Antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs), are the most effective and most commonly used medication in treating this spectrum of illnesses. They are found to be of greatest benefit when used in combination with therapy, and are of little value if offered on their own. In the case of anorexia, these medications are most effective if employed after successful weight restoration is achieved, at which time they can be useful for relapse prevention and the treatment of coexisting psychiatric conditions. SSRIs are also used in preventing binge relapses among bulimics, although their effectiveness ceases once the medication is discontinued. Although antidepressants have also been employed in the treatment of binge eating disorder, outcomes have not been sufficiently positive to warrant recommendations for their use.

Outcomes

Individuals are usually considered to be ready to terminate therapy once they have achieved a healthy body weight and can eat all foods free of guilt or anxiety. For a complete recovery, extensive treatment may be required from six months to two years, and for as long as three to five years in cases where other psychiatric conditions are present. For some, eating disorders will be a lifelong struggle, with stressful or traumatic events triggering relapses that may require occasional check-in therapy to restore healthful eating patterns.

 

Eating Disorders throughout History


Although eating disorders first came to widespread attention in the 1970s, self-starvation and other pathological eating practices are found throughout recorded history. Bulimia was widely known in both Greek and Roman societies and was recorded in France as early as the eighteenth century. Self-starvation for religious reasons became widespread in Europe during the Renaissance, as hundreds of women starved themselves, often to death, in hopes of attaining communion with Christ. During the nineteenth century, as corpulence stopped being viewed as a symbol of prosperity, self-starvation became common again. The incidence of eating disorders varies widely among cultures and time periods, suggesting that they can be encouraged or inhibited by social and economic factors. Eating disorders have most often been seen in affluent societies and are rarely reported during periods of famine, plague, and warfare.


Of individuals with anorexia nervosa, 50 percent will have favorable outcomes, 30 percent will have intermediate results, and 20 percent will have poor outcomes. The prognosis for bulimics is slightly less favorable, with 45 percent achieving favorable outcomes, 18 percent having intermediate results, and 21 percent with poor results. Among both anorexics and bulimics, 5.6 percent will die of complications related to their illness. Those who receive treatment early in the course of their disease have a greater chance of full recovery on both a physical and an emotional level. A favorable prognosis is also likely with an early age at diagnosis, healthy parent-child relationships, and close supportive relationships with friends or therapists. With early identification and treatment, eating disorders can be prevented from becoming chronic and potentially lethal.