Adult Anorexia

WebMD Live Events Transcript

Think anorexia is only for teenage girls? Think again. Some experts believe that more than 10% of anorexics are over 40. What drives an adult to starve herself or himself? And what help is available? Michael Strober, PhD, joined us to answer questions about adult anorexia on Aug. 2, 2005.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome to WebMD Live, Dr. Strober. Thank you for joining us today. Please share some of your background and expertise with us.

STROBER:
I am director of the Eating Disorders Program at the Lynda and Stewart Resnick UCLA Neuropsychiatric Hospital and professor of psychiatry at the David Geffen School of Medicine at UCLA and the Semel Neuropsychiatric Institute. I have been at UCLA since 1975 and I received my PhD in clinical psychology at University of Pittsburgh.

My interests and research involvement has been in the area of eating disorders and mood disorders and I have expertise in a variety of different areas including the long-term study of eating disorders, the treatment of eating disorders and the biology and genetics of these conditions. My interest in treatment and my expertise spans both psychotherapy and pharmacotherapy.

MODERATOR:
When we think of anorexia, probably most people think of young teen girls. But that picture isn't entirely accurate, is it?

STROBER:
Yes, on the one hand, and no on the other. Most cases of anorexia develop between the ages of 13 and 17. It's rare to develop it after the age of 20. At the same time, the illness can be chronic and the course of the illness tends to be fairly protracted, so many people with anorexia nervosa will have symptoms of the illness continuing well into adulthood.

Roughly 3%-5% of people who develop anorexia nervosa will have its illness in its full form for decades, meaning the symptoms will be present acutely well into adult life. So when you consider that the course of the illness tends to be fairly protracted, it is not at all unusual for people who have anorexia nervosa to be of adult age. In my experience, when the illness actually seems to unfold after the age of 20 it is usually foreshadowed by milder symptoms developing during the teenage years.

MEMBER QUESTION:
Do you see a lot of new cases of adult anorexia -- or are people just struggling a lot with recovery and relapse? This is the case with me.

STROBER:
Most of the cases of adult anorexia nervosa involve people who have had the illness since their adolescence who have continuing symptoms or symptoms that wax and wane over time.

MEMBER QUESTION:
Is it likely that a woman who had anorexia in herteens will relapse during a hard time in her adulthood?

STROBER:
People who fully recover from the illness, meaning that they have no residual symptoms, and who maintain that recovery for a period of time, tend to have a very, very low risk of relapsing. If they have mild symptoms that persist over time and then exposed to a major stressful life event, there is a risk of having a relapse, although it is impossible to determine what that risk is, which means you can't quantify it in any way. I think it is fair to say that if you reach a period of recovery, where symptoms are no longer present, and that period of recovery is sustained, then the risk of relapse is significantly lowered, even in the face of stressful life events.

STROBER:
I would not say the treatment is necessarily any more or less aggressive. The answer to the question depends on how long the illness has been present and how aggressive you attempt to address the illness depends in part on the age of the individual, how long they have been ill and how severe their illness is.

When adults have been ill for extended periods of time, the likelihood of recovery is significantly less and there are significant risks of very aggressive treatment. It can cause an intensification of fear, and feelings of threat, such that the treatment can actually be destabilizing and provoke extreme panic which can lead to further aggression. So for adults who have been ill for prolonged periods of time and who are very symptomatic, the recommended approach may be attempting to stabilize the illness rather than attempting anything more aggressive, given that the likelihood of significant change in patients who have been severely and chronically ill through adult life is not high.

MODERATOR:
How does age factor into the aggressiveness of the treatment?

STROBER:
That's a good point. It really is the duration of illness because duration and age tend to be highly associated. Remember that adult-onset anorexia, true adult onset, where you have no symptoms prior to age 20, is extremely rare -- it's very rare. There are cases of adult-onset weight loss but one has to determine if that is truly anorexia nervosa or some other psychiatric illness in which weight loss is a symptom or an acute stress reaction. Pure adult onset of anorexia nervosa is something that is seen very infrequently.

MODERATOR:
What might trigger someone who has had "control" over the illness for a number of years -- what might cause a relapse?

STROBER:
Any significant life stress, regardless of its nature, can provoke an intensifying of symptoms. So for example, a sudden move, a change in job, a stress in a relationship, anything that causes the individual to feel threat of security can produce a regression in behavior and flourishing of symptoms that previously were more controlled.

STROBER:
It's a difficult question to answer. The fact with anorexia nervosa is that if you have the illness without interruption, into your midadult years, the chances of full recovery lower significantly. I would not say that recovery is not possible, but our clinical experience would suggest the odds do fall considerably as the time spent ill increases. The best we can say is that if the person is motivated and can tolerate the discomfort and the feelings of insecurity that will come with weight gain and can use the treatment, then one should always assume there is the possibility of recovery.

MEMBER QUESTION:
I'm a recovering anorexic. I suffered between the ages of 20-23 -- a bit older than the "typical" anorexic. Now I have almost adopted the traits of a binge eater, I think because my body is so excited to get these foods. I deprived myself of for so long, so I stuff myself full of them to the point of sickness. Is this common? Any suggestions on emotional and mental exercises I can do to overcome this? I want to eat according to my own hunger, not out of excitement!

STROBER:
It is not uncommon. Roughly 30% of people with anorexia nervosa develop binge eating and binge eating is something that can be treated. There are both psychological therapies and medications that have been shown to be effective in treating binge eating. Cognitive behavior therapy, interpersonal psychotherapy and antidepressant pharmacotherapy have been shown to be helpful in binge eating, although cognitive behavior therapy is seen by most authorities, or is believed by most authorities, to be the most effective approach to controlling binge eating.

STROBER:
Following the previous question, bulimia nervosa in adulthood is not infrequently preceded by a period of anorexia nervosa, which can be either severe or mild. The majority of cases of bulimia nervosa occur without any history of anorexia nervosa, so for some a period of starvation will increase the risk of subsequently developing binge eating, presumably due to the effects of starvation on feeding behavior.

STROBER:
What you're describing may well be anorexia nervosa, but without a diagnostic consultation, it is impossible to know this for certain. Other possibilities, again, without knowing the background of the history of these symptoms, include an anxious depression with body image disturbance and abnormalities in eating behavior. As mentioned earlier, there are some adults who develop oppressive states and anxious states which can then be complicated by changes in attitude regarding weight and shape and subsequent changes in eating behavior, but this could be a case of anorexia nervosa that has intensified over the years.

MODERATOR:
Can we talk about body image? For women and men approaching a big birthday - 40 or 50 - this can cause a great deal of anxiety about an aging body. Can that be a trigger?

STROBER:
Generally it is not. The adult concerns with health, fitness, appearance, although not unusual, represent a very different phenomena than anorexia nervosa, which is a very deep rooted and serious psychiatric illness, generally making its first appearance in adolescence. So body image concerns, per se, should not be equated with anorexia nervosa, which involves an extreme irrational fear of normal body weight and subsequent dieting, to the point of malnutrition and apparent indifference to the consequences of severe wasting.

STROBER:
It isn't clear that there is a best outpatient treatment. If the fear of normalizing eating and weight gain is so great that you continue to eat restrictively, the illness will be perpetuated, in which case the only viable treatment, assuming you can tolerate its impact, will be inpatient care.

Bear in mind, that the inpatient treatment of anorexia nervosa is uniquely complicated and challenging and should be undertaken in a program specializing in this type of therapy.

STROBER:
The inpatient treatment of anorexia nervosa cannot be undertaken in the absence of specialized expertise and a program ideally suited to the needs of individuals who suffer from this complicated illness.

STROBER:
I would agree that that is not an ideal approach to this illness. Our philosophy at UCLA is that the treatment needs to be prolonged, and for people with severe illness treatment should continue on a daily basis until the person reaches a reasonable target weight range and should remain in frequent and intensive treatment until they demonstrate reasonable ability to maintain the ability to demonstrate stability and independence in maintaining their weight.

Coming into an inpatient program and leaving prior to reaching a reasonable target weight range or transitioning to a day hospital status that doesn't allow for sufficiently intense and frequent treatment, is ill-advised.

The fact is that anorexia nervosa requires intensive and prolonged treatment, usually involving a close integration of inpatient and day hospital care in those cases, where outpatient therapy has not proved sufficient.

STROBER:
I assume that the questioner is referring to weighings in which the patient is not given direct feedback. The rationale is that the anxiety is too great and the information only further intensifies the anxiety. Whether there is or is not a rationale for blind weighing has never really been determined. I agree with the questioner that it cannot necessarily be assumed, with any reliability, that the patient has less anxiety and that this in any way facilitates treatment.

At UCLA we respect a person's wish not to know their weight, but we do not routinely use blind weighing. And have never found the patient's knowledge of their weight a deterrent to treatment.

MODERATOR:
And how do insurance companies in general respond to this? Do they treat anorexia as a physical or mental illness? Are most insurance companies willing to cover the intense and frequent treatment you suggest?

STROBER:
Our experience at UCLA, in the last several years, is that there is increasing understanding on the part of insurance carriers and support for more intensive therapy. That is not across the board, but at least with the insurance companies that we deal with frequently, there is an understanding that this illness requires prolonged and intense treatment.

In California there is parity. There are certain exceptions. For example, the parity extends to group policies but not individual indemnity plans, and in policies that are covered by parity, eating disorders are treated no differently than medical conditions.

STROBER:
I agree. The doling out of benefits for an illness like anorexia nervosa is unfortunate and irrational, and it is certainly possible that had you received a more sustained and intensive treatment, your risk of relapse may have been reduced.

STROBER:
The strength of the illness is likely due to the person's susceptibility to extreme fear and anxiety, and this extreme sensitivity to fear is likely due at least in part, to a biological susceptibility, the exact nature of which is not known, but likely the result of those systems in the brain that regulate fear and the regulation of the extent to which we fear. So if those systems are overexpressed, such that the person is more likely to fear, and less likely to regulate or extinguish fear, then the preoccupation of weight and fear of weight gain lingers on and is more compulsive.

Life events can certainly add to this and further sensitize a person to fear and threat. The basis for this notion is that upwards of 60%-70% of people with anorexia nervosa have anxiety or anxiety disorders unrelated to fear of weight or eating prior to the onset of dieting and weight loss. And anxiety disorders are also elevated in the relatives of people with anorexia nervosa.

MODERATOR:
Dr. Strober, we are almost out of time. Before we wrap things up for today, do you have any final comments for us?

STROBER:
Information about the UCLA program is available by accessing the web at www.npi.ucla.edu or simply by "googling" UCLA Neuropsychiatric Hospital.

MODERATOR:
You have a new book coming out in the fall, Just a Little Too Thin (Da Capo Press) with Meg Schneider. Will you join us again to discuss it?

STROBER:
Absolutely. I'll be happy to come back.

MODERATOR:
Our thanks to Michael Strober, PhD for joining us today.

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