Clinical Professor, Oregon Health and Sciences University and Training and Supervising Psychoanalyst, Oregon Psychoanalytic Institute, Portland
By Kathryn Zerbe, MD
Reprinted from Eating Disorders Review
November/December Volume 24, Number 6
©2013 Gürze Books
While the past three decades have yielded a new and better understanding of the biological, cultural, and psychological factors that underlie eating disorders and that also may assist in their treatment, a central paradox has also emerged. Today, more eating and body image problems are being seen in clinical practice in patients in middle and later life, and these ‘late life eating disorders’ are receiving more attention than ever before in research studies and case reports.
In the 1980s, examples of ‘late life eating disorders’ in the literature were intriguing but rare, and for the most part a biological explanation was given for their etiology and resistance to intervention. In the 21st Century, clinicians see more patients who have maintained full-blown or subclinical eating and body image problems for decades (Zerbe, 1993/1995; 2001, 2008). There is also some emerging evidence that eating problems may develop as part of the menopausal transition, due to hormonal or psychological effects (Mangweth-Matzek, 2013) [also see a related article elsewhere in this issue]. No matter the cause, eating disorders in the older population are dangerous illnesses that beguile practitioners who must be alert to the myriad of medical ‘rule outs’ that must be made before the diagnosis of eating disorder is given (Lapid et al, 2013).
These disorders in later life also raise a serious question for our field as a whole: Have we come as far as we think we have with understanding and treatment? If so, why do many persons, mainly women, have what appears to be intractable concerns with body image? And, like the younger cohort of patients, these individuals will also go to great lengths to keep their problem a secret, or to deny that it exists, and even when informed repeatedly of potential lethal consequences, still maintain dangerous behaviors of over-exercise, poor nutrition and self-care, and purging. Cosmetic surgeries and other anti-aging techniques may be part of the continuum that clinicians also see in our practices that augur for a deeper understanding of how men and women are negotiating, or failing to embrace, expectable and inevitable life transitions. As much as we all may at times be prone to want to turn back the clock, doing so robs us of embracing the present moment and dealing with all of those “necessary losses” that lead to growth (Viorst, 1986).
An Opportunity for Future Therapists
Herein lies opportunity for the next generation of therapists who deal with eating and body image issues. Empathically attuning ourselves to the inner struggle of our patient, we glean that we are only different from them in a matter of degree. All we human beings struggle to some extent with how we feel about our bodies and how we look or present ourselves to the outside world. All the more, we must all deal with aging, loss, and eventually with death. These are just the kinds of problems the patients who enter our consulting rooms want to avoid, but I would argue that many days we therapists do as well. As important as it may be for us to offer concrete tools to patients in the form of education and behavioral intervention, it is also essential for us to tune in to the details of the life story and to give it the space it needs to enfold. Listening quietly, respectfully, and with ‘optimal responsiveness’ (Bacal, 2011) to our patients will offer us new windows of insight into why they, in particular, developed their eating disorder. Their stories hold those ‘secrets that are in plain view,’ about how the eating problem came to fruition and why it maintains itself. This approach will never be the whole story or the end of the story in a field as complex as eating disorders, but without it, we, as much as our patients, will be left the poorer.
Bacal HA. (2011). The Power of Specificity in Psychotherapy: When Therapy Works and When it Doesn’t. Jason Aronson: Lanham, MD.
Lapid M I, Chen Y, Rummans TA, McAlpine, DE, Zerbe, KJ. Eating disorders in later life: A clinical review. Clin Geriatr.2013.Published online June, 2013.
Mangweth-Matzek B, Hoek H, Rupp C, Kemmler G, Pope H, Kinzl J. The menopausal transition – A possible window of vulnerability for eating disorders. Int J Eat Disord. 2013; 46: 609.
Viorst J. Necessary Losses:The loves, illusions, dependencies, and impossible expectations that all of us have to give up in order to grow.1986;Simon & Schuster, New York, NY.
Zerbe KJ. The body betrayed: Women, eating disorders, and treatment. American Psychiatric Press: Washington, DC, 1993 (Published in paperback, Gürze Books, Carlsbad, CA, 1995).
Zerbe KJ. Eating disorders in midlife and beyond:transition and transformation at a crucial developmental stage. Psychoanalysisand Psychotherapy. 2002; 19: 9-19.
Zerbe KJ. Integrated Treatment of Eating Disorders: Beyond the Body Betrayed. W.W. Norton, New York, NY, 2008.