Chronic Eating Disorders in Midlife
By Johanna Marie McShane, PhD
The development of anorexia, bulimia, or a related disorder in midlife is relatively rare, although it is becoming more common. Usually, an individual develops an eating disorder during adolescence and it continues in some form into adulthood. This might be because the illness went undiagnosed, the person was unable to find or stay in treatment, or the disorder appeared to be fully resolved early on, but resurfaced sometime later. This article addresses chronic eating disorders in midlife and how to approach them.
Resolving the Eating Disorder at Different Stages
Eating disorders can be complicated and challenging to treat no matter when they begin. Generally, the longer someone has the illness the more difficult it is to change or resolve. An eating disorder that has been a part of someone's life for 10, 15, or 20 years is different than one that has existed for a few months. Over time, the person with a chronic eating disorder feels she has fewer and fewer other options to cope with emotions and other facets of daily life. She also becomes less connected to other people as a consequence of the illness establishing itself as her strongest, if not, primary, relationship.
Often, a recent disorder will not have become as embedded in someone's life, and in such cases a goal of treatment may be to entirely eliminate the problem. With a chronic condition, a more reasonable objective may be to develop additional coping strategies and ways the person can have a gratifying life, despite the presence, to some degree, of the illness.
Seeking Recovery After 30 Years
A 43-year-old woman came to see me a few years ago. She had anorexia and bulimia for about 30 years and had been in a variety of treatment settings over the past decades. She was frustrated by her seeming "inability to recover," and demoralized that every time she made progress in terms of food, weight, or being more involved in her life, she significantly relapsed, with enough weight loss to leave her medically unstable. She was sure she wanted to recover, but every time she relapsed she felt more like a failure.
Over the first few months in therapy we explored her idea of recovery—what about it appealed to her and what about it frightened her. She realized that after living with the eating disorder for so long she couldn't imagine life without it. She began to understand the dynamics of her relapses: Each time she made a change in her eating or gained weight (for example, letting herself eat a new, previously "bad" or "unsafe" food), or when she participated more in truly living, she felt it meant she was moving toward totally losing the disorder, which terrified her, precipitating a relapse.
Since the approaches she had so far employed to work on her disorder had turned out to be largely counterproductive, we tried something else. We began to conceptualize a life where she could "keep" the disorder, as opposed to continually (and futilely) attempting to get rid of it. She was amazed at the idea that she might not have to "kill it off" and that she could stop expending so much energy in the service of an end result that she, in truth, felt was neither possible nor in her best interest. Giving herself this permission allowed her to explore other options, such as "How to begin to have more of a life I want, even though I might always have some part of this disorder." It also freed her from her belief that she was "bad" and a failure since she hadn't been able to fully recover after so many years of trying.
Managing the Symptoms
In shorter-term eating disorders, the focus may be "How to fully resolve the disorder so the person can resume life," the conceptualization being more akin to an acute medical condition. For example, imagine a course of action one might take in the case of a severe and suddenly occurring bacterial infection. All available resources would be devoted immediately and intensely toward eradicating the disease and returning the individual to health, ideally with little or no remaining effects from the infection.
In a chronic eating disorder, we'd do better to primarily work within the framework of "How can I live the best life possible?" as opposed to "How can I get rid of the eating disorder forever?" The difference in viewpoint can be illustrated by an approach likely taken with a chronic, as opposed to an acute, medical condition. One might hope for major gains in resolving the disorder, but the focus would more realistically be on managing the symptoms and additionally doing whatever one could do to assist the individual in having the fullest, most gratifying life possible. While this approach is not recommended for most cases, in chronic disorders it can be helpful.
No Relapses in Two Years
The aim of acknowledging and accepting differences in treating and overcoming a chronic disorder is not to be pessimistic, but to be realistic, and in fact, as a result, hopeful. Working on one's relationship the disorder is always a worthy endeavor. Remaining cognizant of the length of time the illness has been a part of someone's life and consequently the nature of her relationship with the disorder, affords a structure within which to focus the therapeutic work.
The woman who came to see me a few years ago continues to work on her relationship with her eating disorder. The difference now is that she feels empowered and excited by what lies ahead, not ineffective and immobilized in her life. As a by-product, she has suffered no relapses in the past two years. Ironically, it has been "giving up the idea of recovering fully" that has allowed her to truly progress in recovery.