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David Baxter PhD

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More Middle-aged Women Seeking Treatment for Eating Disorders
October 02, 2006
The Philadelphia Inquirer

PHILADELPHIA - Sorelle Marsh's bulimia began in college.

For a formerly chubby kid still obsessed with food and weight, discovering how to get away with gluttony was a revelation.

Gobbling thousands of calories and then vomiting the food all up "was my best friend," she says. "It was a drug, a way of dealing with everything."

But 20 years later, it had become her worst enemy. So last year, for the first time, the wife and mother of two young children sought treatment for her eating disorder.

"I just hit rock bottom and realized I couldn't do it by myself," Marsh, 43, said recently, sitting on an overstuffed couch in her tastefully decorated living room. "Now, food isn't the issue. I have a lot of anger. I'm still exploring that and trying to articulate it."

Bulimia and the self-starvation called anorexia predominantly affect women in their teens or 20s. But increasingly, therapists are seeing older women who have relapsed decades after successful treatment, or who can no longer hide the health effects of their chronic abuse.

"Western women live in a culture of Body Wars that does not end or disappear when they turn 25 or 30," say psychologist Margo Maine and journalist Joe Kelly, authors of The Body Myth: Adult Women and the Pressure to Be Perfect. "The picture of the young, vibrant teenager who succumbs to an eating disorder is tragic, but eating disorders are just as destructive in the lives of adult women."

It is rare, however, for a full-blown eating disorder to start in middle age.

"There is some data supporting the idea that more middle-aged women are seeking treatment for eating disorders, but this is not the same as saying that more are developing eating disorders for the first time," says Donald E. McAlpine, a psychiatrist and director of the eating disorders program at the Mayo Clinic in Rochester, Minn. "Most of them, in my practice, have struggled with food and weight and body image since adolescence."

Holly Grishkat, director for outpatient programs at the Renfrew Center of Philadelphia, agrees: "When you go back and really look at the woman's life, usually you find some history of disordered eating."

The recognition that eating disorders are distinct psychiatric illnesses goes back only about 30 years. Most experts believe cultural factors have contributed to an increase in the prevalence since then.

Today, up to 1 percent of young Western women suffer from anorexia, while twice as many are bulimic, according to the Academy for Eating Disorders, an international organization of treatment professionals.

Anorexia is by far the more intractable illness; an estimated 20 percent of patients remain chronically ill, and 5-10 percent eventually die as a result. Long-term studies of patients with bulimia suggest that about 10 percent are still regularly bingeing and purging after 10 years.

Treatment centers have begun to develop programs designed specifically for older patients. Renfrew, for example, created separate group therapy sessions for women over 35 after they went from constituting 10 percent of inpatients in 2001 to 17 percent two years later.

Therapists recognized that in the traditional mixed-ages groups, the older women remained silent, or tried to mother the younger women, or complained that midlife issues were not being addressed.

"For older women, it's about loss. Loss of youth, loss of children, loss of parents, loss of a spouse, loss of function," says psychiatrist Susan Ice, Renfrew's medical director. "Treatment often involves helping them work through the stages of grief."

At the same time, adults tend to be highly motivated and cooperative - unlike many teenagers, who deny they have a problem and enter treatment only to appease their parents.

Marsh typifies such motivation.

She traces her obsession with weight to childhood, when her generous but domineering father bribed her to lose weight with the promise of new clothes and trips. At school, she endured relentless teasing, especially in junior high, when she carried 163 pounds on her 5-foot-5 frame.

She dropped to a skeletal 102 pounds in college through fasting and laxative abuse. Then she switched to bingeing and vomiting several times a day. After she married her husband, Eric, 14 years ago, she purged less often, but never stopped, not even during her honeymoon or pregnancies.

In the evenings, after she put her children, ages 5 and 9, to bed - keeping them unaware of what they are too young to understand - Marsh binged and purged downstairs while her husband watched TV upstairs.

"My husband knew, but chose not to discuss it," she says, her lips revealing the perfect white caps that replaced her upper front teeth, which were ruined by gastric acids. "It was an open secret. It was my way of coping, so why would I give it up?"

But she wasn't coping. She felt "suicidally depressed" by the time she entered Renfrew in January 2005 for a six-week stay.

Over the next six weeks, Marsh became a model patient. She "surrendered" to the tight supervision, ate what and when she was told, and gave head scarves to the women in her group - a way for them to build solidarity and not bother about their hair.

She also learned to be more assertive, starting with Renfrew. She was paying about $1,500 a day through health insurance and financial help from her parents, yet her treatment team had skipped a standard wrap-up evaluation, and glossed over unexpected weight loss that she attributed to better eating habits. After all, she seemed to be doing so well.

"It was the first time I ever stood up for myself," recalls Marsh, now weighing 125 pounds. "I say, 'You owe me more than this. If I don't make it now, I don't know how I'll make it.'"

As a result, the center extended her stay for free, she says, so staff could address her concerns.

Family dynamics are another defining difference between adolescent and adult patients.

"With an adult, of necessity you give the patient more responsibility for recovery. It's hard to turn a husband into a food cop," says Michael Pertschuk, medical director of the eating disorders program at Friends Hospital, and of Eating Disorders Treatment Centers in Marlton, N.J., and Feasterville, Pa.

Nicole Coleman, 33, a Philadelphia minister, says that because she was overweight, neither her husband nor her parents suspected she was bulimic. During her two pregnancies, she binged but didn't purge, causing her weight - and self-hatred - to balloon. In May, when she began outpatient treatment at Renfrew, she knew her behavior was putting her life at risk.

"I was throwing up four or five times a day," she says. "I kept zip-lock bags in my car to throw up in, then I'd drive around and drop them in Dumpsters. By the time I got to Renfrew, I was throwing up blood."

Coleman is still struggling - she felt compelled to go on a two-day liquid fast after indulging in a plate of french fries recently - but she is confronting the emotional hunger behind her compulsions.

To women like herself, she offers this advice: "Get help. Every day gets better."
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