SEED is a clinical definition that is modeled after SEMI in the mental disorders framework. SEED stands for severe and enduring eating disorder; SEMI for severe and enduring mental illness.
Please note that this post from 2011 is devoid of references, however these topics are covered and heavily referenced in posts since that time on the topics of depression, SSRIs, anxiolytics, etc. all addressed below.
Dr. Paul Robinson, a leading psychiatrist in the eating disorders field in the U.K., appears largely responsible for the classification and definition of SEED. The primary purpose for such classifications are to ensure that patients receive adequate and continuing support and care.
I have decided to use the non-clinical term EED (enduring eating disorder) instead, as the clinical definition of SEED requires a specific body mass index (BMI) and BMI is a decidedly poor marker of an enduring eating disorder.
Clinicians will apply a SEED classification to any patient beyond the age of 26 that (for whatever complex series of reasons) appears unable to recover. The assignment of a SEED diagnosis to any patient recognizes that the purpose is to ensure continuing support and care. In other words, the classification does allow for the concept that despite its severity and endurance, the patient may reach full remission at any point.
Nonetheless I have been very ethically conflicted in assigning a purely palliative effort when it comes to the eating disorder spectrum. SEED necessarily shifts the focus from recovery to progressive symptom management.
The dilemma is to provide resources and encouragement to continue to pursue full remission while balancing the obligation to respect the individual and provide humane and adequate palliative care in the interim.
It really must be addressed on a case-by-case basis. One patient may feel that a diagnosis of SEED is just writing her (or him) off. Another patient may feel that her progressively more severe symptoms are being overlooked because the focus continues to be exclusively on full recovery. In either case, tremendous depression and hopelessness can result if the wrong approach is chosen.
I will now attempt to tread very gingerly through the topic of palliative care and remission as it applies to those over age 50.
Applying the SEED diagnosis before menopause (or age 50-55 for men) is useful as a way to pull resources to the patient and his or her caregivers, but as much as possible the ongoing effort to recover should be central to the patient’s focus nonetheless.
No matter what, all those dealing with eating disorders have to come to the decision and motivation to recover on their own. Once a patient is in a space to make that decision to recover, then recovery is feasible at any age.
As I mentioned in my post Is it too late for me to recover from restrictive eating behaviors? (ages 26-52) it requires a much more concerted re-training of the pathways in the brain the longer you have practiced restrictive behaviors, but physically the brain is capable of such “re-wiring” the entire time you are alive.
Recovery from the eating disorder spectrum post-menopause (or age 50-55 for men) does not look much different than how I have described it in the post on ages 26-52 with the exception that the body is no longer able to actually reverse osteoporosis, as far as we know given limited clinical information. Nonetheless, the progression of osteoporosis stops upon achieving remission at this age (and beyond).
The decision to avoid recovery at this stage is common and the impacts of that decision are also well documented in my post for ages 26-52.
Why is it common to avoid recovery after age 50?
It’s complicated, of course.
For most, they cannot generate a self-concept of themselves that does not include the eating disorder. Many began restricting around the age 10-11. They have experienced multiple health crises, emergencies, hospitalizations and have cycled in and out of the “real world” as a result.
In fact, even for those with severe schizophrenia, the later onset of full-blown psychoses (somewhere between ages 18-24) is such that more people with schizophrenia than anorexia can recall a “before” state. If your “before” state was experienced at age 10, then there is not much of that existence that is transferrable to a sense of your adult self today.
The inability to conceive of yourself without the eating disorder can be mediated through therapy. By identifying others you know who have never had an eating disorder, or those who have fully recovered, it is possible to create a more detailed anticipation of what you would like to become free from your restrictive behaviors.
Anxiety as a Major Barrier
Another tremendous factor prohibiting recovery at this age is that you have likely experienced extreme anxiety whenever there is any attempt made to apply non-restrictive behaviors.
There are a variety of ways to go at anxiety modulation. Rapid eye movement desensitization and reprocessing therapy (EMDR), often used for post-traumatic stress disorder but showing some promise for the treatment of resistant anorexia, may allow you to address very specific anxiety triggers when you attempt to increase calorie intake or reduce exercise or purging behaviors.
More general forms of desensitization therapies may also be suitable: being guided through the extreme anxiety response to a stimulus (perhaps a particular food that causes severe panic) with the support of a trained counselor or therapist.
Cognitive behavioral therapy (CBT) is clinically proven to support a complete recovery from the eating disorder spectrum. Additionally, for this age group, dialectical behavioral therapy (DBT) may provide a higher level of accountability that is necessary to move through the discomfort of applying behaviors that initially feel unpleasant and alien to you.
Another real undertow for recovery at this age is being too physically and cerebrally compromised to be able to reap the benefits of counseling therapies. Most patients after 30-40 years’ worth of restriction are experiencing significant reductions in cognitive capability; are dealing with starvation-induced psychopathologies (anxiety, depression, perhaps even psychosis); and are physically feeling weak, unwell and overwhelmed.
I do not suggest supplementation for any other age group dealing with these spectrum disorders because it can distract from the primary focus of re-feeding (believing you are covered off with supplements and therefore don’t have to eat a nutritionally complete and healthy amount of food) and it can create dangerous imbalances and toxicities.
If however you are now in your 50s and have struggled with an eating disorder for several decades, then vitamin and mineral supplementation (again, all carefully discussed and cleared with your physician because it can be dangerous) may allow for enough temporary support of your biological functions to allow you to reap some benefit from counseling efforts.
And the counseling efforts are going to be needed to get you into a recovery mind-set and get to a point where you can handle the disordered pushback as you begin to up your calories.
And this brings me to the anti-depressants, anxiolytics and anti-psychotics. No clinical data support their use in the treatment of eating disorders at any age.
There are some provisos to that sweeping statement of course. First of all, anti-psychotics may absolutely be needed if you have developed secondary severe psychosis. Thankfully, developing psychotic symptoms is not common for eating disorders and happens very rarely for extremely emaciated patients in medical crisis and is resolved most commonly with weight restoration.
Anxiolytics (anti-anxiety medication) are generally under-prescribed in today’s world primarily due to successful marketing of the selective serotonin re-uptake inhibitor (SSRI) suite of drugs and secondarily due to hyper-vigilance of licensing related to “the war on drugs”. Anxiolytics are successful in moderating anxious responses and their dependency issues are hugely overrated, nonetheless there is some evidence that they cannot be used in conjunction with EMDR or desensitization therapies as they obfuscate the necessary response that needs to be modulated for treatment to be successful. Furthermore, anxiolytics are more dangerous for the elderly (correlated with more falls and injuries) and so using them in your 50s and 60s might predispose you to habituation that becomes increasingly dangerous for you in your 70s and 80s.
Anti-depressants have approximately the equivalent benefit of a placebo (taking a sugar pill and believing it will work) for major depressive disorder, reduction of binge/purging cycles in bulimia (but only for the duration of being on the drug), anxiety disorders, obsessive-compulsive disorder and numerous other off-label indications. What this means is that any positive outcome from taking anti-depressants is almost wholly attributable to the patient’s own anticipation that s/he will have a positive outcome.
However, that placebo effect is still very valid. About a third of patients who try an SSRI will have an immediate improvement in their depressive symptoms. The rest will have no improvement or really unpleasant side effects that prompt them to stop taking the drug altogether. Another smaller group will experience improvement when they switch from one SSRI to another. But any more subsequent switches provide no improvement.
The guidelines that a patient should persevere with an SSRI for up to 6 months to see if they experience any improvements in their depressive symptoms are not based on any evidence. In fact, if after 14 days the patient has had no improvement, there is little value in continuing.
And finally, for a small subsection of patients, the drug interaction is such that they may never be able to come off of the SSRI because the withdrawal symptoms are too severe.
Yet another subsection experience as part of this SSRI-discontinuation syndrome what are called “brain zaps” or “brain shocks”. The sensation is likened to an electrical shock deep in the brain that can wake you from sleep; disorient you while awake; and can be painful (equivalent to short duration migrainous or trigeminal neuralgias except deep within the brain).
Even very slow tapering from these drugs does not necessarily prevent discontinuation syndrome and while the symptoms dissipate for most, they may not ever completely disappear.
When we consider that 118 million antidepressant prescriptions were filled in the U.S. in 2005, and we hazard a guess that a mere .01% would experience discontinuation syndrome, that impacts 1.2 million patients in the U.S. alone.
Now with all those rather unpleasant facts in place, there may still be value in considering antidepressants in preparation for a concerted effort to fully recover at age 50 or beyond.
There is some reasonable evidence that mitochondrial mutations may be at the root of the genetic neurobiological origins of the eating disorder spectrum.
Mitochondria are the powerhouses of our cells (yes, we likely all remember that one from school biology classes). Mitochondrial DNA (mtNDA) is inherited exclusively from our mothers.
Interestingly, the mitochondria functioning in our brains are essentially helped with increasing levels of serotonin.
Assuming (and I’m going to lean towards it being an assumption rather than fact) that an SSRI does allow for more availability of serotonin to the nerves in the brain, then the addition of an SSRI to treatment of eating disorders at age 50 and beyond may provide some mitochondrial resilience.
Why is that of any use? Well, it may support a concerted effort to recover by minimizing mitochondrial dysfunction that may in turn be linked to lessening symptom expressions of the eating disorder spectrum.
If that is the case, then while SSRIs cannot alleviate behaviors of starving, purging, over-exercising, they may create a neural atmosphere that at least won’t inhibit therapeutic efforts as much (eg. CBT, DBT, EMDR, etc.).
That’s a lot of maybes and each individual has to weigh up his or her own comfort levels with the risks relative to the possible benefits.
Of course many of you will already have been on at least one SSRI for some time and it may have been originally prescribed to address the onset of depression that usually increases as the years go by without complete recovery.
If you have tolerated the prescription then there is absolutely no reason to discontinue it. If you are unhappy with the side effects then remember to discuss the process of tapering off slowly with your physician ahead of doing so.
Recovery is a Learning Process
Fundamentally, at no point from now through the rest of your life, is there anything that prohibits a complete recovery that isn’t the same for all age groups: the decision to embrace recovery.
Lou Batori took up downhill ski racing at age 80. Lydia Davison took up line dancing at 80. Leni Riefenstahl took up scuba diving at 80. Alferd Williams learned to read at age 70. Seaman Dan began his music career at age 70. Elliot Brainard began landscape painting at age 70. Egon Bethge began marathon running at age 80 (all newsprint examples).
I use these examples because they chose to learn something very new at a so-called advanced age. Recovering from the eating disorder spectrum is learning something new. Learning is hard. Learning is awkward. Learning creates anxiety and stress. And learning is human.
Now let’s get back to SEED and EED (finally).
Let’s face it, the reason those septuagenarian and octogenarian men and women were newspaper-worthy is that we don’t all necessarily maximize our ability to learn throughout life and therefore their success is newsworthy.
Our value as human beings is not defined by our ability to learn so much as it is by our ability to be. Unfortunately, the perfectionistic tendencies and black and white thinking that often prevail with more enduring forms of the eating disorder spectrum make it difficult for the patient to feel valuable and successful despite the fact that full recovery has eluded them.
SEED and EED Definitions
So what is SEED? The severity of the eating disorder is necessarily defined by either a very low body weight, or a level of symptom expression that causes severe medical issues and/or has significant impact on trying to live a ‘normal’ life. It also presupposes either a cycling through partial recoveries and relapses, or a constantly active state of the disorder for at least 12 years.
EED is not a clinically recognized classification but I have decided to include it because the spectrum of restrictive eating behaviors does not cease to exist just because the patient is at a BMI of higher than 16.
- SEED would require a BMI of <16 and/or an inability due to medical complications and general health issues originating from ongoing starvation, to either live independently or hold a job to support oneself.Therefore it is possible to be diagnosed with SEED and yet still be capable of living independently and holding down a job.
- EED would involve a BMI ≥16 and an inability due to medical complications and general health issues originating from ongoing starvation to either live independently or hold a job to support oneself. And as a spectrum, EED also will include those who continue to live independently, hold a job, maintain close relationships and yet are increasingly suffering disability as a direct result of progressive energy depletion throughout the body.
What does it mean to be diagnosed with SEED?
While this diagnosis can be applied at any point beyond age 26, it is most applicable post-menopause or beyond age 55 for men.
As I mentioned, the whole rationale for having this specific diagnosis is to pull resources to the patient to improve quality of life.
The shift to palliative efforts from a full-blown recovery push does not have to be perceived as failure.
It’s Just Chronic, Not Hopeless
A reasonable parallel might be to consider long-standing rheumatoid arthritis or perhaps insulin-dependent diabetes as a model by which to frame a SEED diagnosis.
A patient with RA can experience remission at any point, even after many years of struggling through active inflammation and damage. A patient with insulin-dependent Type II diabetes mellitus may be able to make lifestyle changes* that will reverse her need for daily insulin support.
*And just so we're clear, those changes don't include diet and exercise, but rather true lifestyle changes involving extricating yourself from damaging relationships and/or careers and seeking adequate psyhotherapeutic support.
In order to maximize the possibility of remission in the first case and some kind of reversal in the second case, the medical team balances providing pharmaceutical intervention to try to maximize a systemic predisposition in the patient for spontaneous improvement in the underlying medical condition.
Basically, it’s not good enough to pile on the prednisone in RA and tell them to monitor blood glucose and take insulin in diabetes when they can be managing those symptoms and also enhancing the possibility of remission.
By the same token, ignoring the symptoms in favor of having the patient focus on remission is obviously dangerous.
Creating a Space for both Remission and Palliative Support
Basically remission happens when the symptoms are adequately addressed; the socio-psychological atmosphere is reinforcing and supportive; and the patient is sufficiently motivated and has an expectation of success for pursuing changes to facilitate remission.
Think of SEED in this way: You want your medical and psychological team to address adequately the snowballing symptoms of ongoing starvation (or cycles of starvation with reactive eating and/or purging as well as exercise). You additionally want sufficient nutritional supplementation, in whatever way it might be achieved, to maximize cognitive function. A reasonable level of cognitive function can subsequently enhance the socio-psychological atmosphere that in turn will maximize the possibility you begin to experience an expectation of success in attempting lifestyle changes towards remission.
What you don’t want is to have the medical and psychological teams too focused on just watching for deterioration. It is easy to get into the rut of checking the bloods every few weeks, watching for further weight loss, and running regular ECGs to track heart damage and ask a few perfunctory questions on whether any new symptoms have cropped up and are of concern. When in these ruts it is also all too easy to end up using “swallow the spider to catch the fly” prescribing practices.
A general guideline is that if a patient is on four prescriptions, it is likely that subsequent symptoms that crop up are the result of direct interactions between those drugs. If you depend upon your family doctor for addressing your SEED symptoms, you may want to consider a pharmaceutical review with a gerontologist if you are concerned with the number of prescriptions and that it may be hard to tell what symptoms are due to SEED and what might be drug interaction related.
That doesn’t mean you are an old man or woman (!), but rather gerontologists are most commonly exposed to cross-reactivity drug issues as their patients often accumulate prescriptions as they age.
Ideally any consults you have with your medical and psychological professionals, or dieticians and nutritionists for that matter, should be split into a 50/50 progression. Spend 50% of the time ensuring continued stability (no change is good) and the remaining 50% of the time on what might facilitate any efforts toward remission.
Now, the eating disorder part of you is not going to want any discussion on possible changes that threaten the eating disordered way of life you live. Resist the urge not to have the conversation because overall you will feel better for it. Remind yourself in the consult that you don’t have to apply any suggestions (this will assuage the immediate anxiety loop that is fired up when the eating disordered behaviors are threatened in any way), and that talking about possibilities is all it is: talk.
The reason it is beneficial to have the talk about ways towards remission each and every time is that you reinforce your self-worth: I do not view myself as only a medical loser not worth any effort; you reinforce a usefulness for your health care provider: yes, they need to feel they are helping in some way; and you expose yourself repeatedly to what is called the pre-contemplative phase of the process of change.
Maximizing the Usefulness of Your Support Team
Patients that defy prognosis are often found in the SEED category. That they are still alive seems completely anomalous to all our expectations. We should never really cease to be amazed at the ability of the body to fight for us. It does.
But this miraculous survival despite the odds can create complacency in both the patient and in his or her support team. Pay attention to physical changes and if you feel your current health care support is not doing the same, then find new providers.
I often encourage switching health care providers for those in many different stages of the eating disorder spectrum. There is high burnout in health care professionals when it comes to dealing with chronic conditions because fundamentally medicine is not designed for chronicity. But their burnout on your case is not your concern, and so you move on and receive some fresh energy and input.
You don’t have the luxury of leaving your eating disorder, so having committed and enthusiastic support around you is critical for achieving your health goals.
You and a potential new health care professional need an opportunity to assess each other at face value without the possible prejudice that might enter the interaction if your previous health and or psychological/psychiatric records are full of sweeping observations and opinions from former providers with whom you may not agree.
By the same token, you want your support team to have access to each other and your records because many a patient gets into serious medical trouble by failing to ensure that one specialist is aware of another’s involvement etc.
Ideally everything centers on your family doctor or GP. It is a critical relationship and if you are unhappy, then get another family doctor. If you suspect your records from the former GP will complicate subsequent care, then set up an initial introductory consult between you and the new GP. Let the office know that you do not intend to have your records forwarded until you and the new GP are both comfortable with the transfer based upon that initial consult.
Because in most countries specialist visits are dependent upon referrals from your family doctor, if you and your GP are not seeing eye-to-eye then specialist visits are likely to be dissatisfactory as well.
I have covered off some of the progressive physiological and psychological impacts of having active restrictive eating behaviors as you move into your 50s and beyond in my post on ages 26-52.
Just to recap physical concerns, they are:
Physiological effects of chronic starvation are as follows: anemia, hypoproliferative bone marrow (failure), leukopenia (low white blood cell counts), decreased thiiodothyronine, thyroxine and luteinizing hormone levels (polyendocrine deficiency syndrome), abnormal gastrointestinal motility, atrophy and possible ulceration, constipation/diarrhea and amenorrhea. Also usually present are: low basal metabolic rate, cold intolerance, abnormal calcium metabolism, osteoporosis, serum protein abnormalities, electroencephalographic abnormalities (impaired brain function) and altered skin texture and pigmentation.
Physiological effects of chronic bouts of starvation/reactive eating cycles are as follows: all of the previous list for the most part, although anemia is less likely to be present, and also hypertension, elevated low-density lipoproteins (high bad cholesterol levels), artherosclerosis (progressive deposition of fatty deposits on arterial walls, leading to heart disease), excessive subcutaneous abdominal fat due to long term elevated serum glucocorticoid levels.
Yes, these are pretty scary lists. But dealing with any chronic illness is scary. When the symptoms mount up, be it with rheumatoid arthritis, or diabetes, or eating disorders, it is hard to maintain any perspective that there might be a “you” that is not defined by the condition you battle each day.
Mitigating One of the Most Critical Barriers to Remission: Depression
Severe progressive depression, if it is present, is likely due to the effort of living through these chronic conditions and not a distinct co-morbidity that would remain in the absence of the chronic illness.
Side-Lining the Food While Connecting with Friends and Family
With SEED in particular it is difficult to maintain social connections because human social inter-connectedness is founded, built and reinforced through and about the sharing of food. And social connections are protective against depression.
To complicate things further, if SEED patients do maintain social connections it will tend to be with other SEED sufferers. Because there can be competitiveness and reinforcement of restrictive behaviors in these connections, while it may mitigate depression it can worsen restrictive behaviors.
If possible a SEED patient who is in his or her 50s would do well to try to reconnect with non-eating disordered friends but be honest about the need to interact in a non-food centric way.
Thankfully one benefit of aging, whether you have an ED or not, is that you can become a bit more accepting and less self-conscious about many things including having an eating disorder.
Whereas you may have hidden your eating disorder from friends and acquaintances for years, it seems less important to your sense of self to keep it a secret as the years go by and that’s a good thing.
In studies on the stigma of mental illness, it turns out that the general population believes that interacting and speaking with those with eating disorders is most feasible and that it is not hard to connect with them. Of course I would prefer to do away with the entire classification of mental illness in favor of neural conditions, but suffice to say that it is good news that non-ED folk feel comfortable interacting and connecting with people with eating disorders.
If your anxiety about socializing with people is primarily centered on being faced with being pressured to eat and asked invasive questions about why you are not eating, then this can be alleviated by meeting up with one or two friends where they have been made aware of your need to stay off those topics. In these circumstances you can meet them at a botanical garden, art gallery or even see a movie with the understanding that you can do all of that without being interrogated.
If your anxiety is being faced with wanting to eat and trying to resist the need to eat, then you might want to invite your one or two trusted friends over to visit you in a space in which you feel in control and comfortable. Keep in mind, I am not advocating resisting and not eating food (obviously), but I am suggesting within the very narrow definition of SEED you can allow yourself social interactions that support your need for connection in these ways.
Whatever small things you can do to have points in your day that are not all about managing the chronicity of your eating disorder is actually respite for you.
Connection with Protection
On-line communities can be a helpful way to re-connect with non-ED interests and efforts. An on-line book club, or a craft group, or an art or music appreciation group…any of these environments allow you to involve yourself with people and common interests where you can choose to have your eating disorder hidden or not as you prefer. Sometimes it is a relief, especially if you are visibly emaciated, to not answer those questions and still engage with others.
Ideally, combine your efforts of both in-person and on-line activities. If your medical situation has prohibited you from living independently and/or working, then these efforts are particularly important as you have lost the benefit professional interactions that occur in work environments and the casual interactions that may occur with independent living arrangements.
The health benefits of having pets in our lives are clinically phenomenal. For those with chronic conditions the foremost benefits are (this includes eating disorders in this case): perceived alleviation of symptoms (reduction in anxiety likely provides significant altered pain perception); a deep sense of acceptance (you can be how you are and look how you look and the animal feels the same way towards you); a sense of accountability and responsibility that reinforces independence (the pet needs food, water and love no matter what day you’re having); and lower blood pressure, faster healing and lower cortisol levels providing further alleviation of symptoms.
While it can be tempting to want to help in the area in which you are most knowledgeable, namely eating disorders, it is better to consider small and limited efforts in completely unrelated fields.
If you are unable to have pets in your current living circumstances, then working with animals by doing a bit of volunteer work in a no-kill shelter, or with an animal day-care service or vet’s office are good opportunities to experience that connection with animals.
Working with children can provide pleasant respite from your chronic condition assuming you have a supportive and not supervisory role. Volunteer reading aloud for children in libraries is one example.
It is important that whatever volunteer work you might consider, try to choose an opportunity that will allow for periodic ups and downs in health; does not require a level of attendance that puts your health at risk; and involves duties that are complementary to the core service of the organization or outreach so that your occasional absence does not affect service delivery (so that you do not feel compelled to push yourself too hard).
If interacting with others is unappealing, then consider back-room non-critical efforts. Providing your voice for book tapes for the visually impaired is a good option. Doing filing or light organizing for a non-profit is another example. Just knowing your behind-the-scenes efforts help others can ease the pull of depression you may be feeling.
EED: How Does It Differ?
Just as mentioned above the brain’s ability to learn is constant through adulthood, but our ability to embrace learning the older we are is depleted.
Learning is easily achieved with high levels of oxytocin in the brain, which we tend to have in abundance in adolescence and early adulthood.
Oxytocin naturally depletes as we age, so while the brain is just as capable of laying down a new neural pattern (which is learning) as it ever was, the desire to attempt that process is less present at 50 than it was at 20.
So while it seems intuitive that someone a less severe form of an enduring eating disorder would be more likely to attempt a recovery effort, it’s just not so.
The severity of the eating disorder as you enter your 50s in no way predicts the chance of getting to remission.
With absolutely no clinical evidence, I’m going to just bald-facedly guess that it is likely harder to recover (or reach full remission) the less severe the ED symptoms are in your 50s and beyond.
This somewhat educated guess is based on how much you may be exposed to cognitive dissonance (see here). At less than BMI 16, you are seeing many more medical specialists and health care professionals and are made aware of your deteriorating health issues both through your symptoms and corroborating test results. You are regularly pushed to face the dissonance of not wanting to harm yourself and yet continuing to do so.
EED: Spectrum of Severity
If you are periodically visiting a health care professional for various presumably mild to moderate symptoms. Your bone density scans suggest you have mild to moderate osteoporosis and you are on some prescriptions for various symptoms. However, your physician may not have identified that your restrictive behaviors are the root cause of your health issues. In fact, if you are a woman, you may very well have had all your symptoms erroneously lumped in with changes due to menopause.
You are also, at this stage, pretty skilled at deflecting. You will emphasize that you have always had tremendous energy, have worked out, stayed very healthy, no changes in weight…nothing to suggest that you watch every half-pound on that scale and are down to two meals a day both consisting of salad and spring water to maintain that weight. Or, conversely, if you have on occasion purged to deal with a “lapse in control” you are not quick to relay that to your doctor because it doesn’t happen very often at all now, not like it used to.
Furthermore, given mobility in today’s world, the chance that you are dealing with the same primary care physician who has known you since you were 20 is fairly slim. And that means that the current one is unlikely to know that you had amenorrhea through your 20s and 30s, but birth control masked it; that you were able to get pregnant (with some difficulty) and your two children were underweight at birth; that you had a bout of anorexia at age 13, but recovered after your parents took you to a therapist…etc.
That was just a sample scenario to highlight the ways in which you are likely able to avoid any cognitive dissonance – i.e. what you are doing and what you are saying are two completely different things and through avoidance you are do not have to face that huge disparity.
The Up-Side of EED
While cognitive dissonance has to increase greatly to push someone to change and learn new non-restrictive behaviors, if this can be accomplished then the chance of generating a complete remission is very, very good. While there is simply not enough research data out there on those who achieve remission from an active eating disorder (only individual case studies exist), I can say anecdotally from my experience that recovery efforts for mature adults tend to be far less emotionally chaotic, less likely to involve multiple relapses, and more likely to steadily progress towards complete remission than when we look at the 20-something counterparts. However, it is imperative that the brain retraining aspect of recovery be navigated with appropriate psychoeducational support. Decades of restrictive eating practice requires retraining and that must be navigated with therapeutic guidance.
Most of you probably know this poem by Jenny Joseph (1932-)
When I am an old woman, I shall wear purple
with a red hat that doesn't go, and doesn't suit me.
And I shall spend my pension on brandy and summer gloves
and satin candles, and say we've no money for butter.
I shall sit down on the pavement when I am tired
and gobble up samples in shops and press alarm bells
and run my stick along the public railings
and make up for the sobriety of my youth.
I shall go out in my slippers in the rain
and pick the flowers in other people's gardens
and learn to spit.
You can wear terrible shirts and grow more fat
and eat three pounds of sausages at a go
or only bread and pickles for a week
and hoard pens and pencils and beer nuts and things in boxes.
But now we must have clothes that keep us dry
and pay our rent and not swear in the street
and set a good example for the children.
We must have friends to dinner and read the papers.
But maybe I ought to practice a little now?
So people who know me are not too shocked and surprised
When suddenly I am old, and start to wear purple.
And so practice now.