David Cohen, M.D.·Published 29 April 2011·15 min read
Key points
"A decade ago, her eating disorder was getting the best of her, and I was terrified that I'd lose her.
But not everyone who struggles with an eating disorder is young.
In fact, many of those who visit doctors' offices and clinics for help are in their 30s, 40s, or older.
How successfully a person copes with the trials and tribulations of any one stage can influence her ability to cope with the next.
"My daughter is about to turn 35," says Claudia. "A decade ago, her eating disorder was getting the best of her, and I was terrified that I'd lose her. She's doing well now, and I hope she can keep the health she's worked so hard to gain." Perhaps you, like Claudia, have an adult child who suffers from an eating disorder. We've talked at length about the hardships faced by parents whose adolescents are afflicted with anorexia and bulimia, and we've pointed out that these illnesses strike children at increasingly early ages.
But not everyone who struggles with an eating disorder is young.
In fact, many of those who visit doctors' offices and clinics for help are in their 30s, 40s, or older. Is your adult child experiencing food and weight obsession for the first time? Maybe she developed anorexia or bulimia in high school or college and recovered, either fully or partially, but relapsed later in life. Perhaps she has experimented with extreme weight control measures (food restriction, binge eating, purging) in the past or suffered a steady but relatively low level of obsession that escalated into full-blown illness when stress increased. Every stage of life comes with a wide array of challenges regarding body image, self-esteem, and relationships.
How successfully a person copes with the trials and tribulations of any one stage can influence her ability to cope with the next.
The story of Claudia and her daughter will shed light on questions we are frequently asked by adults with eating disorders and their families.
"Sybil is hardworking," says her mom, "but she also has a spunky, lighthearted, and generous side that allows her to make friends easily. As a child, she was sturdy and strong, and her weight was about average. Although she wasn't overweight in her teens, she seemed to think she was. Occasionally she'd say, 'I wish I were thinner,' or 'I'm going on a diet,' but a week or so later, she'd be back to her usual way of eating. To be honest, I didn't try to stop her from skimping on meals, and if I had, she only would have said, 'But Mom, you watch your weight'-and she would have been right. Though I wasn't as serious about dieting as some women I knew, I wanted to keep my youthful figure. Back then, I took dieting for granted as something that came with the territory of being female.
"During her school years, Sybil set high standards for herself.
I never had to remind her to do her homework; in fact, I often encouraged her to close her books at night so that she would get enough sleep. She was always eager to prove herself, not only academically, but also in sports. The pictures I took of her dribbling the ball down the soccer field are so precious. But when I look at them now, my memories are bittersweet. That's because Sybil developed anorexia and bulimia, not during high school or college, but when she was first married and making plans to attend graduate school. Her husband, Darren, went through a lot with her; we all did. When I first found out she was 'sick,' I thought there had to be some mistake. Sybil had always been so sensible.
Written and revised by
David Cohen, M.D.
Our doctors write and review articles for accuracy and keep them up to date.
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Why, just when she seemed to be doing so well, did she start to starve herself?" "I've asked myself that question throughout my recovery,"
notes Sybil, "and I'm still not sure I have an answer. I had supportive parents, a loving husband, all that anyone could dream of.
Yet something was wrong-something about me that I couldn't quite put my finger on was 'bad.' This feeling was familiar but at the same time indefinable. Maybe other people had it, maybe they didn't-I often wondered about that. Now that I've had therapy, I can look back on that feeling-without-a-name and describe it as a sense of being nothing. I viewed myself as having no personality, no particular interests, and definitely no skills. Of all my perceived defects, my stupidity was the most embarrassing, so I bent over backward to keep others from discovering it. When I went away to college, I chose the easiest courses I could to improve my chances of getting good grades. Within my first few weeks in the dorm, I heard my roommates talking about the 'freshman 15.'
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That was the first time I'd heard that expression, which seemed to imply that it's inevitable for women to gain 15 pounds during their first year in college. Looking back, I wish I'd had the wisdom to take that saying for what it was-a myth. But at 18, I took it literally and began to think of weight gain as something scary that I had to guard against; otherwise, it might creep up on me gradually, without my realizing what was happening. Throughout college, I studied a lot longer than other students and held myself to a strict schedule. I also set dietary rules for myself like no bread and no snacks, but I had a hard time sticking to such limits, and I'd gradually drift back to eating what I wanted, only to start a new diet weeks or months later.
"After college, I had three good years working in a children's day-care center. During that time, one of my coworkers introduced me to Darren. He and I hit it off immediately. Our family and friends often commented on how Darren and I were meant for each other. In those early years, he and I just enjoyed being together-it didn't matter where we went or what we did. We were silly, head over heels in love. We talked about building our futures together and eventually becoming parents. We would even chat about our favorite girl names and boy names and joke about what our children might be like. Would they have my quirky sense of humor or what I called Darren's 'special laugh'?
"I enjoyed my work at the day-care center and was interested in advancing my career. I'd always wanted to be a teacher, so I set my sights on graduate school. But when the time came to fill out applications, a familiar sense of 'I'm not good enough' returned full force. I've never been good with uncertainty. I wouldn't say I'm a control freak, but I like knowing what my next move will be well before I make it. When applying to grad schools, I felt the weight of the world on top of me. What if I didn't get accepted anywhere? What would others think of me? Would they realize that I was a fake, that I wasn't as capable as they'd believed? If I were accepted to more than one grad school, which one would I choose? And once I was enrolled, would I be smart enough to do graduate-level work? Without realizing it, I began to channel these insecurities into weight loss. While I continued to worry about grad school, I became very sensitive to the way clothes felt on my body, especially after eating. I wore the baggiest clothes I could find because the sensation of fabric against my arms, legs, or waist gave me the unbearable perception that I'd gained weight.
I experienced my body as thinner and 'better' if my clothes were loose.
"I did not choose to get an eating disorder. In fact, the notion of starving myself to death wasn't even on my radar. If I had any forethought at all about what I was doing, it was a vague hope that practicing some self-discipline and losing a little weight would make me feel better. But as my diet grew stricter, I began to feel frantic most of the time-panicked about my body size and annoyed with anything or anyone who interfered with my routines. The slightest suspicion that I might have accidentally disobeyed a food rule and increased my risk of weight gain would infiate in my mind and take on dire importance. An example of that involved the half a banana I routinely allowed myself after my strenuous 6:00 a.m. run. Hours later, I'd be watching TV or tidying up the apartment when all of a sudden it would occur to me that maybe the banana I'd halved that morning had been longer than average; if that had been the case, I reasoned, I had eaten more than my allotment. My panic level would rise as I'd replay the dividing of the banana over and over in my head to detect whether I'd in fact committed the 'crime' [overeating]. A couple of times, I even examined the evidence by going to the kitchen trash and picking out the peel of the half I'd eaten. I held it end-to-end with the uneaten half to check their combined length, which I then compared to the size of each of the bananas I'd scheduled for the next few days. Part of me felt desperate to prove that I'd done nothing wrong, because I knew that I'd have a high price to pay for my mistake. Inevitably, however, the verdict was 'guilty.' After badgering myself about my carelessness and stupidity for a while longer, I'd impose a penalty, such as no fruit for a week. But within an hour or so of my sentencing, I'd decide that my punishment was too lenient. So I'd make it harsher, perhaps forcing myself to run extra miles. And the 'you're bad, exercise harder' tyrant inside me wouldn't stop until I'd completed every last lap. Once I met that requirement, I might feel some relief. But it wouldn't be long before my mind would grind out another food or exercise demand, and the harangue would start again, often driving me to tears. These obsessions, which I now believe stemmed-at least in part-from intense hunger, greatly interfered with my ability to connect with other people.
"As my weight was slipping away, so was my relationship with Darren. One of my dilemmas was how to avoid eating with him. In the earliest phase of the disorder, we'd sit down to dinner together, and he'd eat while I'd fake it, pushing food around my plate and concentrating more on whether Darren was detecting my abstinence than on our conversation. Pretending to eat was hard, not only because it required a lot of finesse, but also because the food was tempting, and one part of me begged for it while another-more forceful-part said, 'Leave it.' I had no idea that I had an illness and was oblivious to the evidence that my selfdiscipline and weight loss were doing me more harm than good. It seemed easier to stay out of the apartment, especially at mealtimes, so I extended my workouts at the gym well into the evening.
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There were days when Darren would call me from work to ask if I wanted to go to my favorite restaurant for dinner, and I'd say that I didn't feel well or that I'd eaten a late lunch and wasn't hungry.
I felt guilty making up these excuses but would have done anything to stick to my routines and to keep Darren from knowing about my eating habits. A few times, he said that I seemed distant and preoccupied. 'Are you okay?' he'd ask. I'd reassure him that I loved him and that I was fine, just a bit stressed out about whether I'd get into grad school.
"I dreaded intimacy with Darren and tried to avoid it at all cost. I no longer dressed or undressed in front of him. I became so self-conscious about my body and how fat I felt that I was unable to relax when Darren tried to make love with me. I sensed that he felt hurt and rejected by my emotional and physical distance, and I hated myself for making his life miserable. Was I afraid that Darren would leave me or end the marriage? Vaguely. But I never talked about these fears-or any other emotions for that matterin part, because I was only marginally aware that I had them. I'm ashamed to admit this, but had Darren given me a choice between keeping the relationship or keeping my eating behaviors, there was a point in the darkest hours of my illness when I would have selected the latter.
"Luckily, he made no such ultimatum. That is not to say he never got mad at me. Sometimes he'd ask, 'Why can't you just eat?' And when I'd start to become defensive, he'd get exasperated and leave the room. Other times, he begged me to eat, and when I refused, he'd grow impatient and blurt out, 'Sybil, I'm sick and tired of your food problems. I just want to go back to the life we used to have together.' On numerous occasions, Darren expressed concern about my health and urged me to seek professional help.
I wasn't sure what treatment involved, but I assumed that it would make me fat, so I wanted nothing to do with it. What I didn't understand was that professional care would help me feel better.
Darren was so worried about me that he called my parents. I was furious about that. Between the three of them, they convinced me to see my primary care doctor.
"The weeks immediately after my discharge from the hospital were, I think, particularly hard for Darren. At least part of him had expected me to come home 'cured,' and when he realized that I still had eating problems, he was understandably upset. Since I had very little to say to him, he started leaving me handwritten notes. At first, he'd write just a few sentences, highlighting that he loved me and that he was there for me. He didn't know it at the time, but those quiet reassurances meant the world to me and touched me in a way that his attempts to 'talk reason' to me had not. Later, when I continued to struggle with my food problem, he wrote me two letters that revealed some of his private thoughts about our relationship. The second one had a particularly powerful effect on me:
Dear Sybil, I write this with some hesitation. On the one hand, I don't want to upset you-the last thing I'd ever want to do is set off another bout of starving or purging. On the other hand, you and I both know that things between us are not the same as they once were. I'd like us to mend the gulf, and I'm hoping that airing my feelings in this letter will be a first step in the right direction.
When you are under the power of your eating disorder, I sometimes feel that I am irrelevant or even a nuisance to you. It seems like you care more about whether you can get to the gym by 5:00 than about spending evenings with me; I hope that isn't true. I miss the days when you and I were equal partners, when you were stronger and fun to be with.
I don't know how to say this exactly, so please excuse me if it comes out wrong, but sometimes I've felt that your eating disorder changes you from the vibrant woman I married into a sick person who needs to be taken care of. There are also times when I feel that maybe our relationship, or maybe something I've done, has contributed to your eating disorder. Will you help me sort these questions out so that we can both be happier? Love, Darren
"I wish I could say that Darren's letter turned my life around.
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But the truth is far more complicated. At that point, I'd regained some of the weight I'd lost after I was discharged from the hospital, but I was binge eating and vomiting, and my recovery from my eating disorder was still a ways off. I didn't know it at the time, but sorting out our marital difficulties would take a lot of hard work. Looking back, I can understand why Darren wrote that letter; he felt that my eating disorder had changed my personality, taken over my life, and pushed him away. Since I was barely talking to him, he wasn't sure what was left of our relationship, and his letter was an attempt to find out. But when I first read the letter, I wasn't able to see his point of view. Instead, I felt like I'd been hit by a tidal wave of criticism. I sensed 'I'm bad' coming from so many different directions that I could barely keep my head above water. That's where individual therapy helped. I was afraid that my therapists were mad at me for starting to binge, so I didn't want to tell them much about what was going on. But as it turned out, they were not angry and just seemed to want to get to know me better as a person. I liked that. Soon, my treatment team adjusted the dose of my antidepressant medication [a selective serotonin reuptake inhibitor], which began to take the edge off my dark thoughts, making it easier to get through the day.
"When I mentioned the tension between me and Darren to my therapists, they viewed my recognition of this problem as a sign of progress and encouraged me to elaborate. A few weeks later, they suggested that Darren and I consider couples counseling, which would offer us an opportunity to work on our relationship together under the guidance of a therapist. At first, I didn't like the idea because I was afraid the couples sessions would focus on how I was ruining our marriage. But when I told Darren about the recommendation, he was surprisingly receptive, even mentioning that our problems were no one's fault and that he couldn't imagine how we could fix our marriage without professional help.
Deep inside, I sensed Darren's openness to couples counseling was right, so we signed on, attending sessions every week for more than a year. This work proved invaluable in a number of ways.
First, we hadn't shared our feelings openly for so long that we'd almost forgotten how. The counseling helped us break the ice so that we could communicate more effectively. In addition, the joint sessions helped each of us see where the other was coming from and-as Darren had requested in his letter-explore how my eating disorder had affected our relationship and vice versa."
In discussing the impact of an illness on a marriage, it is important not to overgeneralize or oversimplify. Every interpersonal relationship is different and complex. Like Sybil, many people with eating disorders are so engrossed in their food and exercise routines that they cannot communicate in ways that are necessary to develop and sustain healthy relationships. Darren began to feel angry at Sybil, rejected by her, and sad to have lost the woman he had loved. Such feelings are not unusual among the significant others of people who suffer from eating disorders. Under such circumstances, couples therapy can prove very productive.
Looking back, Sybil tried to put couples counseling in perspective. "It wasn't a magic bullet," she explains. "It couldn't undo the pain of the last several years or get back the idealism and bliss that we enjoyed during our first year of marriage. But couples sessions did make a positive difference in our lives, not only by addressing the past but also by helping us look ahead. I was 29 years old. Four long years after my eating disorder had developed, my nutrition had improved, and my body was healthy. Darren and I began to think about starting a family.
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David B. Herzog, M.D., Debra L. Franko, Ph.D., Pat Cable, RN
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David B. Herzog, M.D., is the Harvard Medical School Endowed Professor of psychiatry in the field of eating disorders at Massachusetts General Hospital and the director of the Harris Center at Massachusetts General Hospital. Debra L. Franko, Ph.D., is a professor in the Department of Counseling and Applied Educational Psychology at Northeastern University and the associate director of the Harris Center at Massachusetts General Hospital Pat Cable, RN, is the director of publications at the Harris Center.