When Midlife Seems Just An Empty Plate


The New York Times


IN her 23 years as a specialist in eating disorders, Dr. Margo Maine has received countless telephone calls from women worried that their teenage daughters might be dieting into a danger zone. But several years ago, Dr. Maine, a psychologist who runs an eating-disorders treatment program with a partner in West Hartford, Conn., noticed a shift in the telephone inquiries.

”Increasingly, our calls began to include a significant number of adults seeking help not for their children but for themselves,” Dr. Maine said. Some of those callers — women in their late 40’s and early 50’s — were relapsing after overcoming eating disorders in their youth, and others were experiencing them for the first time.

Naomi Burton Isaacs, a public relations executive in New York, had been obsessed about her weight most of her life, she said, but it was only at age 45 that her dieting grew extreme and she developed an addiction to laxatives. She swallowed 25 pills a day. Ms. Burton Isaacs, who is 5-foot-9, withered to 105 pounds.

”My whole life was shaped by this,” she said. ‘I didn’t want to take trips with people or visit my in-laws, because they had only one bathroom.” Fearing that she was on the verge of a heart attack, she sought treatment, which meant visits twice a week to a psychologist specializing in eating disorders. Through therapy, she drew a connection between her disorder and the difficult state of her marriage, to a man whose midlife crisis, she said, had propelled him toward alcoholism.

”I couldn’t control my husband’s drinking, and I didn’t feel as though I could control anything,” said Ms. Burton Isaacs, whose husband has since died. After six years of therapy, she now weighs a healthy 135 pounds and has thrown away her scale, she said.

Starvation diets and the cycle of bingeing and purging have long been considered afflictions of affluent white females in their teens and 20’s. Although medical literature in recent years has shown eating disorders spreading across class, race and gender lines and striking girls at ever younger ages, the next large group of sufferers, many experts predict, will be middle-aged women. The anxieties of midlife — divorce, marital strains, parental deaths, empty-nest syndrome and menopause — are powerful catalysts for older women’s eating disorders, the experts say.

At its core, an eating disorder, whatever the age of the sufferer, typically results from feelings that one’s life is ”out of control,” as patients tell clinicians, with compulsive food monitoring offering an illusion of emotional management.

Like adolescence, the years before menopause can prompt fears about progressing to life’s next stage. ”The 12-year-old anorectic doesn’t want to deal with the feeling of becoming a woman, and the 50-year-old doesn’t want to deal with the idea of lost youth,” said Dr. Ellen Schor Haimoff, a psychologist in New York and a former director of the Association of Bulimia and Related Disorders. She, too, has seen an increasing number of middle-aged patients with eating problems.

It is not just anxiety about aging, but a fear of aging in a culture that is 20 years into a fitness obsession that are at least in part responsible for setting off midlife eating disorders, many clinicians say — or more commonly, for reviving disorders dormant for many years. ”Baby boomers are not comfortable with the idea of aging into larger figures,” said Dr. William Davis, the director of research at the Philadelphia-based Renfrew Center network, the nation’s largest treatment provider for anorexia nervosa, bulimia and compulsive exercise disorder, with over 30,000 patients since 1985. Dr. Davis, who has observed a rise in the number of new patients over 30 in the past three to six months, added, ”I very much believe that eating disorders will spread upward at the time of onset.”

Broad studies of eating disorders have looked at race and income level, but no national data has been collected showing how many sufferers are women in their late 30’s, their 40’s or their 50’s. Anecdotal reports from several leading treatment centers contacted for this article, as well as physicians and mental-health professionals who treat patients, suggest that eating disorders are now steadily on the rise among women approaching or already in middle age.

No one knows exactly why. In addition to anxieties over fading youth and other midlife issues, the numbers could be rising because of demographics — more women are reaching midlife as the baby boom ages — and because of publicity given to eating disorders in the past generation, which may have spurred those who suffer to seek treatment.

At the 13-year-old Remuda Ranch, the country’s second-largest program, which treats about 650 patients a year in Arizona, only 3 percent of those admitted before 1997 were over 40. Since then, the over-40 share has more than doubled, Dr. Edward Cumella, Remuda’s director of research, said.

”For the longest time, experts said there were no reported cases of eating disorders developing over the age of 40,” Dr. Cumella said. ”People are not saying that anymore.”

A similar rise was observed at the Cornell Eating Disorders Program in White Plains. A study that appeared in 2001 in the International Journal of Eating Disorders on changing patterns of hospitalization among 1,185 patients showed that those age 40 to 49 accounted for 9 percent of admissions at Cornell in 1998, twice as many as a decade earlier. (The study looked at data only through 1998.)

”I think what happens in middle-class and upper-class societies is that women, when they get older, naturally gain weight, and at the same time their husbands go through their own crises,” said Dr. Katherine Halmi, a co-author of the Cornell study and the director of the eating disorders program at the Westchester division of New York-Presbyterian Hospital.

”Some women, in response to their husband having an affair or merely the fear that he will, become obsessed with their weight,” Dr. Halmi said. ”These wives fear that they are competing with women in their 20’s for their husbands’ attention. That’s clinically what I am seeing.”

Dr. Kathryn Zerbe, director of behavioral medicine at the Center for Women’s Health at Oregon Health and Science University, told of a 64-year-old patient who has binged and purged for much of her life.

”She is successful, she has money and she’s charismatic,” Dr. Zerbe said. ”But she’ll come in and say: ‘I hate those 24-year-olds out at parties. They wear their miniskirts and they look fantastic, and I want to kill them.’ ”

Such worries have plagued women for ages, of course, but psychologists assert that the cultural pressure to look 23 at 45 has never been so palpable as now. The modern bag of beauty tricks — including cosmetic surgery, Botox and personal trainers — has created an image bank of faces and bodies, especially of celebrities, that appear permanently fixed at college age. ”The bar for beauty has gone up and up,” Dr. Schor Haimoff said.

Often, doctors and psychologists say, body-image disorder in an older woman manifests itself with compulsive exercising — days organized around hours of jogging, tennis and other calorie-burning activities.

”Overexercising is huge,” Dr. Zerbe said. ”It is a form of a midlife crisis, but it doesn’t look like crisis — it looks adaptive. The exercise is a way of avoiding looking at what’s going on internally. It’s a way for these women to avoid mourning the things they haven’t done in their lives.”

The precise causes of eating and body-image disorders — cultural, psychological, biochemical — are unknown, and other experts and patients cite cases seemingly unrelated to fear of fading sex appeal.

”My anorexia had nothing to do with my physical appearance — it was the absolute bottom of the list,” said Linda Palsky, a registered nurse in Yardley, Pa., who became anorexic at 44. Her weight plummeted to 85 (she is 5-foot-4); she wore children’s clothes; for breakfast she would eat an orange, and for lunch, a Mentos candy.

She said she thinks the immediate cause was the death of her best friend and a horrific accident that befell her father at a time of mounting midlife stresses.

”The middle 40’s for any woman are somewhat traumatic,” said Ms. Palsky, who is also the vice president of her local school board. ”Your kids are getting older. You suddenly look at your husband and think, 20 years? And then there are hormonal changes.”

”I felt like my life was spiraling out of control,” she added.

Today, after treatment, Ms. Palsky, who has two children, weighs about 125, which she considers healthy.

Treatment can involve one-on-one psychotherapy, group therapy or nutritional counseling, or often a combination of all three, for people who are either in residential programs or are being seen as outpatients. At Renfrew treatment centers, a patient typically has six group therapy sessions a day, individual therapy four times a week and nutritional counseling twice a week.

Though some experts contend that older women are more difficult to treat because their habits are longer-standing and more ingrained, others say that adults enter treatment with a greater sense of commitment. Teenagers, who may see an eating disorder as a form of personal rebellion, are often sent into treatment by their parents.

”With adults, because they are in your office on their own motivation, you are already starting off with a different set of issues,” said Dr. Maine, of the West Hartford program.

In some cases, a woman might seek specific treatment for an eating disorder at a psychotherapist’s suggestion. Three years ago, while being treated for depression, a 50-year-old former city planner living in New England was persuaded by her therapist to enter a psychiatric hospital for anorexia, a condition she had been unable to talk about or address. But the woman, who asked that her name not be published, left the hospital after two days. Eighteen months ago, she began weekly psychotherapy sessions with an eating-disorders specialist. She said she is still in the grip of her disease and, at 5-foot-4, weighs ”in the 80’s.”

The woman struggled to stay thin throughout her teens and 20’s, she said, but when her husband was told he had a chronic illness a few years ago her problems grew worse.

”I never wanted to have children, because I didn’t want to be tied down,” she said. ”Suddenly I had someone who needed a lot of care.”

The youthful lifestyle she and her husband had enjoyed — dinners out, trips to Europe and Palm Beach — was curtailed. Her eating became dangerously ascetic. Often, she eats only one meal a day, a salad.

”I wake up in the morning and think, ‘How long can I go without eating anything today?’ ” she said. ”The longer you go — it’s like a high.”

She exercises habitually, in a regime that includes walking on a treadmill for an hour every day, seven days a week; lifting weights with a personal trainer three times a week; and taking Pilates instruction twice a week. Her goal in psychotherapy ”is to become happier with myself and more confident,” she said.

”I’d like it if this eating problem could recede to the back burner,” she said. But she admitted, ”I don’t ever think, ‘Oh, wouldn’t it be nice to go up to 100 pounds?’ ”

”I like the way I look,” she said. ”I look young, and I have a lot of energy. I feel that I’m fine the way I am, which is the problem.”


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