ANOREXIA NERVOSA IN FEMALES OVER AGE 25
Anorexia nervosa may occur after age 25 in females
(72,73,74). The oldest reported patient was a 68-year-old
woman with no prior history of eating disturbance. While
the incidence of anorexia in the general population
is 0.37 per 100,000 (74), the incidence of anorexia
nervosa in old age is unknown. Less than 100 older patients,
both male and female, have been reported in the world's
literature (48,72,74,76,77,78). Adult onset cases usually
come from upper middle class families (72).
Anorexia is a symptom seen in other disorders such
as severe melancholia (79), schizophrenia (80), and
somatization disorder, and in various medical conditions
such as carcinoma, orthopedic injuries (81), central
nervous system disorders as such Wernicke's encephalopathy
(82), and infilitrating hypothalamic tumor (83). Anorexia
(food refusal) not meeting the full DSMIII criteria
may occur secondary to purely psychological causes such
as hysterical food refusal and food aversion due to
somatic pain (74).
Precipitating factors antecedent to the occurrence
of anorexia nervosa in susceptible patients include
multiple surgical procedures or illnesses (76), stress
secondary to childbirth or marriage (77), or death of
a spouse (73).
In married anorectics whose dependency needs have
been shifted to their children, the child's absence
resulting from moving or marriage has been associated
with an acute onset of anorexia (72).
Sexual abuse may be involved in the development of
anorexia nervosa in vulnerable women. Sloan and Leichner
(20) recently described seix anorectic women, first
hospitalized as adults, who were sexually abused in
childhood or adolescence. The adult patients reported
feeling ashamed and embarrassed, and they defended the
abuse because of intense super ego pressures, only later,
in therapy, revealing the sexual harrassment.
Numerous onset patterns have been described. The most
common pattern is one in which the patient has a chronic
eating disturbance or peculiar eating habits and a stress
produces a full-blown clinical expression of anorexia
nervosa. In other patients, an anorexic episode may
have occurred as an adolescent, followed by a long remission,
with stressful events serving to precipitate anorexia
at a later time in young adulthood. The most uncommon
pattern is an adult patient who develops anorexia de
novo (74). The therapist must obtain a very detailed
history of the patient's early eating patterns to determine
if a prior episode occurred.
Some patients who exhibit pure restrictive anorexia
develop bulimia during or after treatment. Failure of
symptomatic restraint may first be manifested in bulimic
episodes. Vandereycken (74) suggests that some anorectics
who fail treatment develop vomiting, purging, or frank
bulimia. Kellett and Associates (77) described a 52-year-old
woman who purged and vomited in addition to the anorexia.
In a study of 50 married patients, Dally (72) divided
anorectics into four groups (see Table 1). In Group
I, onset of anorexia started during the engagement period
prior to marriage. In Group II, onset occurred while
subjects were married and prior to a pregnancy. Onset
in Group III occurred within three years of becoming
pregnant. The period after menopause marked the onset
of anorexia in Group IV. Dally felt that the anorexia
that developed in Groups I and II was a maladaptive
solution to an emerging marital crisis.
Average Ages of Patients and Husbands (72)
Average Age Average Age of Patient | Average Age of
Husband | At Marriage When Seen at Marriage ____________________________________________________________________________
( 7) 21.8 years 23 years 27 years
(range 20-25) (range 22-38)
Group II (18) 22 years 25.6 years 28 years
(range 19-30) (range 21-46) (range 20-47)
Group III (14) 22.9 years 32.5 years 27 years
(range 20-24) (range 22-45) (range 22-47)
Group IV (11) 24 years 59 years 29.5 years
(range 21-29) (range 41-80) (range 23-35)
In Group III, women developed anorexia after childbirth.
The preexisting lack of warmth and understanding in
their marriages was complicated by a feeling of being
trapped by the responsibility of raising children. Unable
to express their turbulent emotions, they retreated
In Group IV, women developed anorexia after menopause.
These women were withdrawn and depressed, and their
anorexia was related to their wish to die, an actual
or threatened loss, the death or serious illness of
the spouse (36%), or the marriage or dispersal of their
children (45%). These women, who had problems with their
own separation-individuation and dependency, were overwhelmed
by the threatened loss of a spouse or their children,
which stirred up their own unmet dependency needs.
Dally (72) reported a varied picture of premorbid
problems. In his study, 44 percent of Groups I and II
had an earlier episode of anorexia nervosa. Patients
who developed anorexia nervosa at or shortly after marriage
were more likely to have had a previous anorexic episode.
The post-menopausal group had no prior episode but displayed
transitory eating disorders with weight loss and food
fads in earlier years.
Most patients desiring a child hoped for a close mother-child
relationship but were fearful of both childbirth and
the responsibility of being a good mother. The older
group (IV) had more conflicts concerning motherhood,
were sick and depressed in pregnancy, and were depressed
and anxious during the child's assertive stage. The
child's developmental issues may have stirred up their
own unresolved conflicts centering on identity and separation-individuation.
Marital conflicts were manifest in all groups, centered
around closeness and intimacy. The patients felt themselves
to be failures, unlovable, and greedy. Husbands, who
were classified in three categories (I-III), were considered
immature and over-idealized by their wives. They felt
anger at the anorexic behavior and either colluded in
the wife's illness, which created a strong dependency
bond (50 percent), or emotionally detached themselves,
putting their energy into another relationship.
No consistent family interactional patterns were recognized
from Groups I and II. However, patients from Group I
through Group III were strongly dependent on their parents,
even if they had married, raised children, and lived
apart from their family of origin (72).
The course of anorexia nervosa in later life is variable.
Crips (84) notes that some chronic anorexic patients
who have the illness throughout their reproductive life
(puberty to menopause) shed the illness at menopause,
while others remain ill, surviving as "isolated,
eccentric, and wizened old ladies."
Vandereycken (74) conceptualizes anorexia as an incurable
illness in some patients with spontaneously occurring
remissions and exacerbations. This chronic course seen
in older patients is a form of "process" anorexia
nervosa, as differentiated from a more "reactive,"
self-limited disorder seen in younger, mainly adolescent
patients. Furthermore, Vandereycken likens anorexia,
with or without bulimia, to an addiction, including
the development of malignant autonomy, apparent physical
dependency, social descent, and physical deterioration.
Dally (72) notes that Group IV post-menopausal-onset
anorectics are markedly depressed and suicidal and may
have a more ominous course than their younger counterparts.
Treatment of the late-onset patient is complex, and
risks such as a psychotic reaction or suicidal depression
may occur with refeeding.
Treatment modalities should include nutritional counseling
and individual psychotherapy. Family therapy with the
spouse and children is indicated to work through family
conflicts and disruptions associated with illness. The
use of a psychotrpic medication in older anorexic patients
to increase weight or mood has not been evaluated. In
Dally's Group IV menopausal anorectics with major depressive
disorder, a clinical trial of a tricyclic antidepressant
may be useful.
Though some patients with late onset or chronic anorexia
nervosa may recover after intensive treatment, patients
failing to maintain their weight at four- to eight-year
followups may have to inevitably recognize their decision
to remain anorectics. In these cases, the goal of treatment
is to minimize the physical and emotional handicaps
of the disease.
Vandereycken (74) raises ethical questions concerning
treatment of chronic anorectics and bulimics. Although
the patients may feel life is barren with anorexia,
life may become even more barren and painful without
it. Furthermore, chronic bulimics can organize their
life around the bulimia, with bulimic episodes becoming
Anorexia nervosa after adolescence may occur in women
who have not worked through developmental issues of
identity or separation-individuation. They remain dependent
on their parents and, to a lesser extent, on their husbands.
They feel ineffective, dependent, and conflicted due
to their ideal wish to be a "good" mother
and wife. Unable to control their lives, they control
their bodies, returning to a state of "goodness"
by developing anorexia nervosa.
Women beyond age 25 who develop an anorexia syndrome
and whose medical examinations fail to demonstrate another
etiology should be carefully evaluated for anorexia
nervosa as a positive diagnosis.