Eating disorders in women

In the most severe cases, patients develop life-threatening complications, such as cardiac arrhythmias, kidney failure, and liver failure. This is one reason that anorexia nervosa is one of the most deadly psychiatric disorders, killing 5.6% of patients for every decade that they remain ill. Treatment is challenging because starvation not only severely damages the body, but also harms the brain — causing changes in thinking, emotions, and behaviors that may be difficult to reverse.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) describes two subtypes of anorexia nervosa. In the restricting subtype, patients drastically reduce food consumption. They may also exercise excessively in an effort to lose weight. In the binge-eating/purging subtype, patients lose weight by forcing themselves to vomit or by using laxatives, diuretics, or enemas.

Once weight decreases to the threshold required for a diagnosis of anorexia nervosa, patients may experience changes in thinking processes, such as difficulty concentrating. They may develop odd food rituals, such as cutting food into tiny pieces, eating only at certain times, and weighing food. Weight gain may eventually improve these psychological problems, but it seldom eliminates them completely — which is why maintenance treatment is so important.

Bulimia nervosa. Bulimia nervosa is characterized by a cycle of binge eating followed by some type of compensatory action to avoid weight gain. Researchers estimate that one to three women out of 100 will develop bulimia nervosa at some point in their lives. In men, the rate of diagnosis is only about one-tenth the rate in women.

Although many Americans overeat by consuming too many calories per day (which helps explain why more than one in three are obese), binge eating involves consuming extreme amounts of food within a restricted time frame — usually within two hours. While on a binge, a patient may eat an entire cake rather than one or two slices, or a full gallon of ice cream rather than a bowl.

The DSM-IV describes two subtypes of bulimia nervosa, based on the strategy a patient uses to rid herself of excess calories. Patients diagnosed with the purging subtype, the most common form, may make themselves vomit or use laxatives or diuretics. This diagnosis overlaps with the binge/purge subtype of anorexia, but people with bulimia do not have the same preoccupation with maintaining a low body weight. In the nonpurging subtype, patients may exercise excessively or stop eating for a day or longer.

If a vicious cycle of overeating and deprivation takes over, patients may eat to the point of physical pain, then compensate so dramatically that they feel ravenously hungry. When the binge-and-compensation cycle occurs at least twice a week for three months, patients meet DSM-IV diagnostic criteria for bulimia nervosa.

Binge-eating disorder. Binge eaters regularly binge, usually in secret and accompanied by feelings of guilt or shame. Unlike bulimics, they don’t follow a binge with a purge, so they may be overweight or obese, and their eating disorder may remain unrecognized. In the DSM-IV, binge-eating disorder is categorized as an “eating disorder not otherwise specified,” but it is proposed for inclusion as a freestanding diagnosis in the next edition of the diagnostic manual. Many older women do not fit the strict definitions for eating disorders, yet they deserve treatment.

Grief. With age, people are increasingly likely to lose people they care about. Mourning can take away your appetite, and restricting food or purging can be a way to deal with distressing feelings. For example, the comedian Joan Rivers has written about the sudden onset of bulimia in her 50s after her husband’s death by suicide.

Divorce. In addition to grief and loss, the breakup of a marriage can spur a woman to view her body unfavorably in comparison with other singles or an ex-spouse’s new girlfriend.

Heightened awareness of aging. This can be particularly acute when women return to school or work or need to keep working past the traditional retirement age, especially in appearance-related fields.

Medical illness. If a short-term illness results in weight loss, a woman may receive compliments on her slender appearance and continue to restrict food after she has recovered to avoid regaining weight.

On the other hand, some older women decide to get professional help after years of disordered eating. This decision may emerge for any of several reasons.

For example, eating disorders take a physical toll on the body, and the impact is more apparent with age. Dental problems, arrhythmias (irregular heartbeats), or osteoporosis (a common complication of eating disorders) may prompt a woman to seek treatment. In an older body, forceful vomiting may result in a medical emergency, such as a stomach rupture or tear in the esophagus, which can bring a woman to professional attention.

A woman’s priorities may also shift over time. Disordered eating and attempts to hide it take a great deal of time and effort. Sometimes an unrelated health scare, death of a loved one, or other event sparks a realization of the sheer amount of psychic and physical energy required to maintain these behaviors, and a woman may finally decide that enough is enough — and seek treatment.