Since the late 1990’s, Remuda Ranch Program for Eating Disorders has experienced a 400% increase in patients 40 years of age and older, according to the authors of this paper. However, we don’t really know what the similarities and differences are between women who develop eating disorders in adolescence and those who develop their eating disorders in midlife (40-65 years of age).
It has been theorized that EDs in midlife may be triggered by midlife transitions, such as loss of parents, siblings, or children; divorce; traumatic illness; and empty nest syndrome (Harris & Cumella, 2006; Maine & Kelly, 2005; Shellenbarger, 2004). […] Two quantitative studies found a high correlation between the fear of aging and disordered eating in older populations (Gupta, 1995; Lewis & Cachelin, 2001).
In this paper, Edward Cumella and Zina Kally present a summary of 50 women who first developed eating disorders at the age of 40 or above and were admitted to inpatient treatment at Remuda Ranch. They “assessed patients’ sociodemographics, severity-of-illness, comorbid diagnoses, personality profiles, and short-term treatment outcomes.”
- Mean age: 49.5 (range: 41 – 63)
- Mean ED onset age: 45 (range: 40-62)
- Mead ED duration: 4 years
- Previous treatment: 40% had prior inpatient treatment
- Race: 98% of patients were White
- Marital Status: 58% were married, 28% divorced/separated, 10% never married and 4% widowed
- Education: 54% had college or post-graduate degrees, 22% had some college education, 20% had a high school diploma, 4% did not complete high school
Cumella and Kally wanted to find out more specifically how this group of women differed from adolescents with eating disorders in terms of diagnosis characteristics, self-harm, suicide, and sexual abuse histories, as well as psychiatric comorbidities and general ED psychopathology.
- 38% were diagnosed with anorexia nervosa, restricting type (ANR)
- 20% with anorexia nervosa, binge-eating/purging type (ANBP)
- 8% with bulimia nervosa (BN)
- 34% with EDNOS
- 76% of EDNOS patients engaged in restricting only, no bingeing/purging
Self-harm, Suicide & Abuse
- 22% of patients had a history of self-harm
- 28% had previously attempted suicide
- 64% had a history of sexual abuse
What about psychiatric comorbidities?
Comorbid Disorders (Axis I)
- 94% were diagnosed with comorbid Axis I disorders
- 86% had unipolar depression, with 60% diagnosed with major depressive disorder and 28% with depressive disorder not-otherwise-specified
- 62% had one or more anxiety disorders
- 18% had substance abuse/dependence issues
- 6% had bipolar disorder
Comorbid Disorders (Axis II – Personality Disorders)
- 24% had Cluster B disorders/traits [Antisocial, Borderline, Histrionic, Narcissistic]
- 20% had Cluster C disorders/traits [Avoidant, Dependent, Obsessive-Compulsive Personality Disorder]
- 2% had Cluster A disorders/traits [Paranoid, Schizoid, Schizotypal]
These findings are informative, but they become really interesting once you compare them to what has been published about adolescents with eating disorders.
For example, on the Eating Disorders Inventory Questionnaire (EDI-2), which is commonly used during diagnosis and assessment, this sample of women scored rather moderately on the drive for thinness, bulimia, and body dissatisfaction measures.
This is strikingly different from admission EDI-2 scores of younger inpatient ED populations, where the three primary scales are typically elevated into the ED range (Cumella, Kally, & Wall, 2007; Garner, 2004). Instead, on the EDI-2, patients admitted in the ED range on the ineffectiveness, perfectionism, interpersonal distrust, and asceticism scales, suggesting a possibly greater focus on these issues than the more traditional ED issues of body image and binge/purge behaviors.
Notice that the majority of the patients did NOT exhibit any binge-eating or purging behaviours, something that I don’t think we would have seen if this had been a sample of women who first became sick during adolescence and either never truly recovered or relapsed in middle age. The difference between 8% with bulimia nervosa in this sample to 40% in teenagers and young adults (Blinder, Cumella, & Sanathara, 2006) is quite striking.
The majority of midlife-onset ED inpatients (64%) appeared to have ED diagnoses of ANR and EDNOS with only restricting behaviors. This predominance of pure restriction resembles ED patients in the earlier stages of an ED (Fairburn & Brownell, 2002).
Interestingly, comorbid depression and anxiety was similar in frequency but reduced in severity compared to what has been reported in adolescents with eating disorders. Substance abuse/dependence were also less frequent in this sample than in teenage and young adult ED inpatients, and the drugs of choice tended to be of the sedating (as opposed to stimulating) type.
Cluster B (antisocial, borderline, histrionic, narcissistic personality disorders were really high in this sample compared to what is seen in adolescents. This is especially interesting because those disorders and traits tend to be primarily seen in patients with bulimic symptoms (which were relatively infrequent in this sample). Conversely, Cluster C personality disorders (avoidant, dependent, obsessive-compulsive (not to be confused with obsessive-compulsive disorder!)) were relatively rare compared to what has been reported in younger ED populations.
The authors suggest these findings warrant additional research. Perhaps pursuing this research will provide us with more information about the differences between adolescent-onset and midlife-onset eating disorders in etiology, phenomenology, and treatment.
Self-harm was less common though sexual abuse history was much more common than in younger ED populations. I would love to find out at what age these women first began self-harming and when they experienced sexual abuse (was it in adolescence or closer to the time of their eating disorder?). Hopefully this, along with the finding on personality disorder comorbidities, is something that will be explored in future studies.
As always, I like to point out the limitations of a study. Please keep in mind this was a small sample (just 50 women, though of course, that’s to be expected given the study was about midlife-onset of EDs). Secondly, the patients were not interviewed for the study, instead their chart data was reviewed sometimes many years after the patients were in treatment. There is no comparison group to young patients in the same facility, and the sample consists of treatment-seeking patients in a faith-based facility.
Whether these findings are generalizable to the general population of women with midlife-onset eating disorder remains to be observed. In particular, I wonder about midlife-onset of bulimia, and about the characteristics of non-treatment seeking women (and men, of course). How do they differ from these women and from adolescents with eating disorders (or adolescent-onset eating disorders).
Cumella, E., & Kally, Z. (2008). Profile of 50 Women with Midlife-Onset Eating Disorders Eating Disorders, 16 (3), 193-203 DOI: 10.1080/10640260802016670