Anorexia nervosa may occur after age 25 in females (72,73,74). The oldest reported patient was a 68-year-old woman with no prior history of eating disturbance. While the incidence of anorexia in the general population is 0.37 per 100,000 (74), the incidence of anorexia nervosa in old age is unknown. Less than 100 older patients, both male and female, have been reported in the world's literature (48,72,74,76,77,78). Adult onset cases usually come from upper middle class families (72).

Anorexia is a symptom seen in other disorders such as severe melancholia (79), schizophrenia (80), and somatization disorder, and in various medical conditions such as carcinoma, orthopedic injuries (81), central nervous system disorders as such Wernicke's encephalopathy (82), and infilitrating hypothalamic tumor (83). Anorexia (food refusal) not meeting the full DSMIII criteria may occur secondary to purely psychological causes such as hysterical food refusal and food aversion due to somatic pain (74).

Precipitating factors antecedent to the occurrence of anorexia nervosa in susceptible patients include multiple surgical procedures or illnesses (76), stress secondary to childbirth or marriage (77), or death of a spouse (73).

In married anorectics whose dependency needs have been shifted to their children, the child's absence resulting from moving or marriage has been associated with an acute onset of anorexia (72).

Sexual abuse may be involved in the development of anorexia nervosa in vulnerable women. Sloan and Leichner (20) recently described seix anorectic women, first hospitalized as adults, who were sexually abused in childhood or adolescence. The adult patients reported feeling ashamed and embarrassed, and they defended the abuse because of intense super ego pressures, only later, in therapy, revealing the sexual harrassment.

Numerous onset patterns have been described. The most common pattern is one in which the patient has a chronic eating disturbance or peculiar eating habits and a stress produces a full-blown clinical expression of anorexia nervosa. In other patients, an anorexic episode may have occurred as an adolescent, followed by a long remission, with stressful events serving to precipitate anorexia at a later time in young adulthood. The most uncommon pattern is an adult patient who develops anorexia de novo (74). The therapist must obtain a very detailed history of the patient's early eating patterns to determine if a prior episode occurred.

Some patients who exhibit pure restrictive anorexia develop bulimia during or after treatment. Failure of symptomatic restraint may first be manifested in bulimic episodes. Vandereycken (74) suggests that some anorectics who fail treatment develop vomiting, purging, or frank bulimia. Kellett and Associates (77) described a 52-year-old woman who purged and vomited in addition to the anorexia.

In a study of 50 married patients, Dally (72) divided anorectics into four groups (see Table 1). In Group I, onset of anorexia started during the engagement period prior to marriage. In Group II, onset occurred while subjects were married and prior to a pregnancy. Onset in Group III occurred within three years of becoming pregnant. The period after menopause marked the onset of anorexia in Group IV. Dally felt that the anorexia that developed in Groups I and II was a maladaptive solution to an emerging marital crisis.

Table 1

Average Ages of Patients and Husbands (72)

Average Age Average Age of Patient | Average Age of Husband | At Marriage When Seen at Marriage ____________________________________________________________________________ Group I

( 7) 21.8 years 23 years 27 years

(range 20-25) (range 22-38)

Group II (18) 22 years 25.6 years 28 years

(range 19-30) (range 21-46) (range 20-47)

Group III (14) 22.9 years 32.5 years 27 years

(range 20-24) (range 22-45) (range 22-47)

Group IV (11) 24 years 59 years 29.5 years

(range 21-29) (range 41-80) (range 23-35)

In Group III, women developed anorexia after childbirth. The preexisting lack of warmth and understanding in their marriages was complicated by a feeling of being trapped by the responsibility of raising children. Unable to express their turbulent emotions, they retreated into anorexia.

In Group IV, women developed anorexia after menopause. These women were withdrawn and depressed, and their anorexia was related to their wish to die, an actual or threatened loss, the death or serious illness of the spouse (36%), or the marriage or dispersal of their children (45%). These women, who had problems with their own separation-individuation and dependency, were overwhelmed by the threatened loss of a spouse or their children, which stirred up their own unmet dependency needs.

Dally (72) reported a varied picture of premorbid problems. In his study, 44 percent of Groups I and II had an earlier episode of anorexia nervosa. Patients who developed anorexia nervosa at or shortly after marriage were more likely to have had a previous anorexic episode. The post-menopausal group had no prior episode but displayed transitory eating disorders with weight loss and food fads in earlier years.

Most patients desiring a child hoped for a close mother-child relationship but were fearful of both childbirth and the responsibility of being a good mother. The older group (IV) had more conflicts concerning motherhood, were sick and depressed in pregnancy, and were depressed and anxious during the child's assertive stage. The child's developmental issues may have stirred up their own unresolved conflicts centering on identity and separation-individuation.

Marital conflicts were manifest in all groups, centered around closeness and intimacy. The patients felt themselves to be failures, unlovable, and greedy. Husbands, who were classified in three categories (I-III), were considered immature and over-idealized by their wives. They felt anger at the anorexic behavior and either colluded in the wife's illness, which created a strong dependency bond (50 percent), or emotionally detached themselves, putting their energy into another relationship.

No consistent family interactional patterns were recognized from Groups I and II. However, patients from Group I through Group III were strongly dependent on their parents, even if they had married, raised children, and lived apart from their family of origin (72).

The course of anorexia nervosa in later life is variable. Crips (84) notes that some chronic anorexic patients who have the illness throughout their reproductive life (puberty to menopause) shed the illness at menopause, while others remain ill, surviving as "isolated, eccentric, and wizened old ladies."

Vandereycken (74) conceptualizes anorexia as an incurable illness in some patients with spontaneously occurring remissions and exacerbations. This chronic course seen in older patients is a form of "process" anorexia nervosa, as differentiated from a more "reactive," self-limited disorder seen in younger, mainly adolescent patients. Furthermore, Vandereycken likens anorexia, with or without bulimia, to an addiction, including the development of malignant autonomy, apparent physical dependency, social descent, and physical deterioration.

Dally (72) notes that Group IV post-menopausal-onset anorectics are markedly depressed and suicidal and may have a more ominous course than their younger counterparts. Treatment of the late-onset patient is complex, and risks such as a psychotic reaction or suicidal depression may occur with refeeding.

Treatment modalities should include nutritional counseling and individual psychotherapy. Family therapy with the spouse and children is indicated to work through family conflicts and disruptions associated with illness. The use of a psychotrpic medication in older anorexic patients to increase weight or mood has not been evaluated. In Dally's Group IV menopausal anorectics with major depressive disorder, a clinical trial of a tricyclic antidepressant may be useful.

Though some patients with late onset or chronic anorexia nervosa may recover after intensive treatment, patients failing to maintain their weight at four- to eight-year followups may have to inevitably recognize their decision to remain anorectics. In these cases, the goal of treatment is to minimize the physical and emotional handicaps of the disease.

Vandereycken (74) raises ethical questions concerning treatment of chronic anorectics and bulimics. Although the patients may feel life is barren with anorexia, life may become even more barren and painful without it. Furthermore, chronic bulimics can organize their life around the bulimia, with bulimic episodes becoming "institutionalized."

Anorexia nervosa after adolescence may occur in women who have not worked through developmental issues of identity or separation-individuation. They remain dependent on their parents and, to a lesser extent, on their husbands. They feel ineffective, dependent, and conflicted due to their ideal wish to be a "good" mother and wife. Unable to control their lives, they control their bodies, returning to a state of "goodness" by developing anorexia nervosa.

Women beyond age 25 who develop an anorexia syndrome and whose medical examinations fail to demonstrate another etiology should be carefully evaluated for anorexia nervosa as a positive diagnosis.