From ARFID in Adults to Anorexia: Chicago Therapists Explore Eating Disorders in Midlife & Older Adults

Written by: Angela Derrick, Ph.D. & Susan McClanahan, Ph.D.

Date Posted: September 26, 2024 9:32 pm

From ARFID in Adults to Anorexia: Chicago Therapists Explore Eating Disorders in Midlife & Older Adults

Written by Angela Derrick, Ph.D. and Susan McClanahan, Ph.D. with contributions by Alison (Ali) Mayer, NCC, LCPC.

ARFID in adults, along with other eating disorders including anorexia and bulimia, are likely to go unrecognized in midlife stages (40-60 years old, give or take a decade) and in older adults (65+) for many reasons, not the least of which is the stereotype that these illnesses are relegated to the young. 

Midlife is a pivotal period that involves acceptance of where we are in life as we seek to balance gains and losses. We are also uniquely positioned to bridge generations by raising our kids, supporting them in early adulthood, and caring for aging parents. Finally, this is the time in life when we begin to confront the vulnerabilities of being human more seriously. 

The unique set of circumstances and stressors in mid to later life can cause overwhelm and increase the prevalence of mental health issues such as anxiety, depression, and eating disorders. Understanding the stages of psychological development as a cumulative process where successful navigation and adaptation at one stage informs and provides the foundation for the next can help us recognize and seek treatment from a qualified therapist when this process breaks down. 

Erik Erikson’s theory of psychosocial development outlines eight stages that individuals go through from infancy to late adulthood, each marked by a specific conflict that needs to be resolved for healthy psychological growth. 

Infancy Through Teenager

The first stage, “Trust vs. Mistrust,” occurs in infancy, where developing trust in caregivers sets the foundation for future relationships. As individuals progress, they face other conflicts, such as “Autonomy vs. Shame & Doubt” in toddlers, “Initiative vs. Guilt” in early childhood, and “Industry vs. Inferiority” in school-aged kids. Teenagers confront “Identity vs. Role Confusion,” learning to form a sense of self. 

Adulthood

In adulthood, the conflicts shift toward “Intimacy vs. Isolation,” “Generativity vs. Stagnation,” and finally, “Integrity vs. Despair” in old age. Later, Erikson and his wife Joan amended their theory to include a 9^th stage of life, during which the challenges previously faced resurface and must be re-confronted and reworked. Successfully resolving these conflicts fosters virtues like hope, purpose, and wisdom, contributing to overall well-being.

The challenges in mid to later life can be unlike anything we’ve faced before. As we age, there can be changes in social roles, feelings of diminished worth and competence, as well as identity confusion. Our attempts at self-protection (defenses), such as accumulating wealth, sexual conquest, having a high-powered career, running marathons, and nurturing children at the expense of ourselves may no longer suffice as we get older. 

The unique confluence of mid to later life stage concerns and stressors such as changing bodies, taking care of aging parents, weathering the cost and stress of raising kids, infidelity and divorce, dealing with an empty nest, and unemployment or retirement are just a few of the factors that can increase the likelihood of triggering eating disorders, anxiety, and depression in adulthood or worsening the disorders that have been present throughout the life span. This New York Times article reports that even the U.S. Surgeon General has recently issued a rare warning that parental stress is an urgent public health issue.

The notion of a midlife crisis (coined in 1965) is more a developmental one than one of a particular age. Research suggests that the midlife crisis is not normative and occurs in only 10-20% of people. In today’s world, many of these “midlife” transitions might happen later in life through empty nesting, coming to terms with limitations, confronting mortality, and caring for aging parents. One of the greatest measures of our ability to navigate these transitions successfully is our sense of interconnectedness. Having and nurturing authentic relationships gives us much-needed resilience as we age.

It is no mystery that midlife stressors coupled with the aging process can make us vulnerable to eating disorders in order to cope. It is important to note that eating disorders are much more than just coping mechanisms. They are a serious and sometimes fatal mental health disorder that needs to be addressed and treated by a mental health professional with expertise in eating disorders. The following are a few informative statistics regarding mental health and eating disorders in adulthood:

• Rates of depression, anxiety, and serious mental illness are highest at midlife, particularly among women, those of low socioeconomic standing, and those who identify as LGBT (Brody et al., 2018; Frederiksen-Goldsen et al., 2018). ​
• Use of antidepressants and engagement with a mental health professional is higher for individuals ages 40-60 compared with younger or older cohorts​.
• Caregiving duties affect health, employment opportunities, and work-life balance, with over 44 million U.S. adults providing unpaid family care.
• According to a 2010 study, the majority of clients who are midlife or older with an ED struggled with Anorexia Nervosa vs. other eating disorders. (MulChandani, Shetty, Conrad, Muir, and Mah, 2021)
• Later onset of eating disorders was more commonly seen in clients at midlife or older vs. earlier onset. (MulChandani, Shetty, Conrad, Muir, and Mah, 2021)
• Research shows that roughly 20% of eating disorder clients who are midlife or older end up relapsing or dying from eating disorder complications. (MulChandani, Shetty, Conrad, Muir, and Mah, 2021)

While anorexia nervosa shares many common symptoms across all age groups, some specific symptoms and complications may be more pronounced or unique in adults due to the often prolonged nature of the disorder and the different life stages they are in. These adult-specific challenges highlight the need for tailored treatment approaches that address both the physical and psychological long-term impacts of anorexia in adults.

Here are symptoms of anorexia that are more likely to be unique or amplified in adulthood:

• Adults with anorexia are more likely to experience severe bone density loss, leading to osteoporosis, making fractures and bone breaks more common. This risk increases with age, especially if anorexia has persisted for years.
• Prolonged malnutrition in adults can result in more severe damage to organs such as the heart, liver, and kidneys. Heart complications, such as bradycardia (slow heart rate) and arrhythmias, can be more dangerous in older adults with anorexia.
• Adult anorexia can lead to infertility issues in women due to hormonal imbalances, and in men, it may result in decreased testosterone levels and reduced libido.
• Adults with anorexia often experience more pronounced social and professional consequences. The disorder may lead to absenteeism, inability to focus, and eventual job loss or career stagnation.
• Anorexia in adults can also cause withdrawal from romantic and family relationships. This isolation may be heightened in adults due to the societal expectations of being able to maintain family life or intimate partnerships.
• Adults with anorexia often suffer from more persistent and debilitating fatigue, muscle weakness, and overall reduced stamina. Over time, their ability to work, exercise, or maintain daily responsibilities may significantly diminish.
• While mood disturbances like anxiety and depression are common in anorexia across all ages, in adults, these symptoms are often exacerbated. Feelings of guilt, shame, or frustration about not meeting adult responsibilities can lead to heightened mental health struggles.
• Adult women with anorexia may experience an early onset of menopause due to chronic malnutrition. For those nearing the menopausal age, anorexia can worsen hormonal fluctuations, contributing to irregular periods or cessation of menstruation altogether.
• In men, anorexia can lead to a reduction in libido and sexual function due to decreased testosterone levels.
• In both adults and young people, anorexia may be driven by perfectionism or a need for control, which may manifest in rigid behaviors, particularly around work, relationships, and personal responsibilities. Adults often face added pressures related to careers, finances, and social standing, intensifying these tendencies.
• Adults may struggle more with long-term behavioral patterns, making anorexia challenging to treat as restrictive eating and body image issues may be deeply ingrained.
• Adults with anorexia may become increasingly focused on preventing the physical signs of aging, such as wrinkles or weight gain, and use restrictive eating as a way to maintain a youthful appearance. This fear of aging can worsen body dysmorphia and heighten the desire for thinness as a way to maintain control over aging.

Avoidant/Restrictive Food Intake Disorder (ARFID) is an eating disorder where individuals avoid or severely restrict certain foods, leading to nutritional deficiencies, weight loss, and difficulties in daily functioning. Unlike other eating disorders, ARFID is not driven by concerns about body image or weight.

While Avoidant/Restrictive Food Intake Disorder (ARFID) can occur in both adults and children, there are several key differences in how the disorder manifests and impacts these age groups:

Developmental Context

ARFID in children often stems from developmental issues such as sensory sensitivities, food aversions, or fear of negative experiences with eating (like choking). It is sometimes seen as an extension of “picky eating,” but much more severe, interfering with growth and development.

ARFID in adults may be a continuation of childhood patterns, but it can also emerge in adulthood. It may be driven by similar sensory aversions or fear-based avoidance. Adults also face more significant social and occupational ramifications, as restrictive eating patterns can hinder social interactions and behavior at work-related events.

Nutritional Impact

The primary concern for children with ARFID is the impact on physical development. Since childhood is a critical time for growth, ARFID can lead to stunted growth, delayed puberty, and developmental delays due to poor nutrition.

In adults, the focus is more on the long-term health effects of poor nutrition, such as chronic fatigue, weakened immune function, and increased risk for conditions like osteoporosis or anemia. The absence of major developmental milestones means that while growth isn’t a concern, maintaining physical health is a priority.

Social and Psychological Impact

Children with ARFID may face issues in school or with peers due to their restricted diet, but adults typically provide structured meals and care. Children might not fully understand or articulate their food-related anxiety.

Adults with ARFID often struggle more with the social aspects of eating, such as dining out, attending social gatherings, or even work-related functions. As adults are expected to navigate social situations more independently, the disorder can create significant isolation and anxiety.

Insight and Self-Awareness

Young children with ARFID might not have a clear understanding of their disorder or the reasons for their food avoidance. They are more likely to express frustration or confusion about their eating habits.

Adults with ARFID are more likely to be aware of their restrictive eating patterns and the associated distress, but they may have a harder time changing long-established behaviors. Adult insight often comes with increased guilt, frustration, or shame about the limitations ARFID imposes on their life.

Treatment Approaches

Treatment for children often involves family-based therapy and parental involvement, focusing on ensuring proper nutrition and encouraging the introduction of new foods through gradual exposure.

Adult treatment tends to focus more on individual therapy, often using cognitive behavioral therapy (CBT) to address underlying fears and anxieties about food. Therapy also targets practical issues like eating in social settings or meal planning.

In both adults and children, ARFID requires a tailored approach, with interventions designed to expand dietary variety, address nutritional deficits, and reduce the psychological stress associated with eating.

There are many reasons eating disorders have been misidentified and under-reported for those who fall into the midlife to older adults category, including:

• The history of eating disorders was only just added to the DSM in the 1980s
• The persistent stigma around behavioral health and eating disorders
• A belief that eating disorders are a teenage disease
• A diet culture that promotes weight stigma
• Shame, which leads to fear of seeking support
• Eating disorders may be diagnosed as other medical conditions or an organic problem.
• Midlife individuals may be better able to mask an illness vs. their younger counterparts.

A History of the DSM’s Role in Diagnosing Clients Over 30 Years Old

Originally, eating disorders were thought to occur in people who were between 16 and 25 years old. Even in the 1980s, the DSM III confirmed this by stating that Anorexia Nervosa could only be diagnosed in people who were under 30 years old. Could this be a reason why eating disorders are underdiagnosed in older clients?

It was not until the DSM IV that eating disorders got their own section in the DSM and were taken out of the infancy, childhood, and adolescent categories. However, in the DSM IV,  a critical criterion for Anorexia Nervosa included amenorrhea, which led to discounting women who were going through menopause and, by extension, all men. It was not until DSM V came out in 2013 that amenorrhea was removed from the Anorexia Nervosa diagnostic criteria.

The Presence of Multiple Disorders

Research has shown that mood disorders are often present in clients diagnosed with disordered eating. When mood disorders are seen as the primary diagnosis, the eating disorder might be missed. More than half of the clients with eating disorders in midlife and beyond also had at least one other psychiatric condition, most commonly depression. (Lapid, Prom, Birton, McAlpine, Sutor and Rummans, 2010)

Midlife Men & Veterans with Eating Disorders

A recent study found that men struggle most with binge eating and bulimic symptoms, where excessive exercise is the primary form of purging. In addition, men who are military veterans and are diagnosed with an eating disorder are also most likely to have Bulimia Nervosa, with purging via excessive exercise, and they have a higher rate of developing PTSD and Depression vs. veterans without an eating disorder. 

Eating Disorders are often masked in Midlife and Later-life males and can be disguised under the trend of healthy living and lifestyle. Age-dependent testosterone levels (andropause) in aging males also seem to play a role in the development of disordered eating. EDs in men are often accompanied by depression, anxiety, and suicidal ideation. (Mangweth-Matzek, Kummer, and Pope, 2016)

LGBTQIA+ Population with Eating Disorders

• In 2017, researchers estimated that 2.4% of the U.S. population 50 years and older identified as LGBTQ+, accounting for 2.7 million people. By 2060, they say, that number is expected to double to 5 million.” (Miller, 2023)
• “Older LGBTQ+ adults have higher rates of anxiety, depression, eating disorders, loneliness and suicidal thoughts, compared with their heterosexual counterparts.” (Miller, 2023) 
• “Older LGBTQ+ adults are less likely to have caregiver support compared with their cisgender heterosexual counterparts,” leading to less mental health support and lower quality outcomes. (Miller, 2023)

More Contributing Factors for Eating Disorders in Adulthood

• Adverse Childhood Experiences
• Poverty
• Trauma
• Marginalization
• Racism and Microaggressions
• Discrimination and Sexual Harassment in the Workplace

The Impact of a Global Pandemic on Eating Disorders

From social isolation to the rise in social media usage and comparison culture to loss of jobs and food insecurity, the pandemic added to our anxieties about our health, which saw an increase in using food for control when otherwise unable to control what is happening in the world.

Further impacting the crisis, “Research shows that exposure to stressful news coverage leads to heightened psychological distress for the person watching, and ultimately poorer attitudes about eating” (Frye, 2021)

When we talk about eating disorders in mid to later-life individuals, we are including those who are currently age 45 and over, Baby Boomers, and Gen Xers born between 1944 and 1979. This generation grew up completely analog and graduated to a fully digital adulthood. It’s hard to conceive of an internet-free life, but they lived it.

Boomers and Gen Xers, in particular, grew up immersed in diet culture with a lot less understanding of the harmful effects of dieting or diet products. They saw their elders using techniques or methods that were later found to be harmful, i.e., Slim Fast, Fenfluramine/Phentermine, the grapefruit diet, cabbage soup diet, Dexatrim, Redux, lemon diet, nicotine, Sleeping Beauty diet, and Weight Watchers in childhood, to name a few.

Because of their upbringing, contemporary ideas of anti-diet, eating moderately, trusting one’s body, and health at every size may be jarring. These ideas are likely contrary to the messaging they were previously exposed to and have believed in for a lifetime. Unpacking decades of diet propaganda can be intense and will likely require an open mind, willingness to learn a new way, help from a group of like-minded people, and, if you have the means, reaching out to a qualified therapist.

Adults with eating disorders are often facing an uphill battle just to have their disorder recognized. Sufferers frequently struggle with high levels of shame, difficulties accessing treatment resources, and discrimination by clinicians. When an adult is faced with shifting towards recovery, it can impact the whole family system. The family might not like this shift, and circumstances will often worsen before they get better. Eventually, the family will have to shift, too, which can feel like an upheaval. 

Having a team that includes a dietician, primary care doctor, psychiatrist, and medical specialists who work with older adults and have training/experience with eating disorders can significantly aid in recovery. Types of therapies will likely include a combination of psychotherapy, family-based treatment, nutritional therapy, occupational therapy, and physical therapy. 

We also encourage joining groups where the members are dedicated to recovery and get it. Building meaningful connections to combat isolation will be one of the best actions you can take to build resiliency and help with recovery. The most significant protective factors at midlife include having the following support systems:

• Supportive partner
• Deep friendships​
• Close community​
• Family support​
• Access to fresh local food.
• Developing a plan for upcoming changes​
• Engaging in psychotherapy 

If you don’t have traditional forms of support, there are ways to build your own. For instance, many of us have a family we choose rather than the one we were born into. There are many creative ways to build community, such as starting a book club, organizing for a cause you believe in, participating in community gardens or the arts, joining a bird-watching club, or taking an improv class. Do all these things alone or with a friend – the possibilities are endless. When we cultivate deep connections, we can escape isolation and loneliness and create the life we want. 

At SpringSource Psychological Center, we understand that eating disorders, especially in midlife and older adulthood, are severe and complex mental health conditions. Ultimately, the most effective healing approach will vary depending on the individual’s unique needs, circumstances, and readiness for change. The Therapists at SpringSource are qualified to provide the most effective and compassionate care for individuals struggling with eating disorders. We also offer evidence-based recovery for anxiety, depression, trauma, and relationship issues.

We believe there are many paths to healing and look forward to helping facilitate your recovery journey. With offices in downtown Chicago and Northbrook, we offer in-person and virtual support. Call SpringSource today at 224-202-6260 or email info@springsourcecenter.com  | We offer free 15-minute initial consultations—schedule here.