As many of you already know, it is as if you become invisible after age 25 when it comes to sourcing information about how to recover from the eating disorder spectrum. You may have been sub-clinically starving for years now, or you have cycled in and out of clinical bouts of starvation, or you may have shifted from starving to cycles of starving and reactively eating, or now you restrict through excessive exercise (as examples).
This post addresses the following demographic of those over the age of 25 but still premenopausal (roughly ages 26-52). The data you will find in this post are generally applicable to males in this age bracket as well, except for the marker of menopause obviously.
It is not too late for you to recover. However, you have to address cognitive dissonance (which I will explain) to be able re-commit to a dedicated effort towards full remission and I hope this post will help guide you through the process of renewing that commitment to recover now.
What Is Cognitive Dissonance?
Just as high-traffic areas in your home wear in carpets and floors, the number of years you have practiced restrictive eating behaviors has created high-traffic areas in your brain. You travel through your brain automatically along these high-traffic pathways of restriction. Imagine if you spent an entire day taking pathways in your home that are outside of the high-traffic areas--squeezing up against the wall of a hallway to avoid walking along the well-worn middle path; walking around the couch the other way; or getting into bed from the end of the bed instead of the usual side of the bed. By the end of the day of traveling through your home in this way, you'd be both physically and mentally exhausted. Of course, you do it enough times and it becomes easier, requires less conscious thought and eventually is as automatic as walking those high-traffic areas once were. Not only that, if you attempted to go back to the high-traffic pathways after two months of walking the low-traffic pathways, it would feel odd and awkward. In fact, you have a new set of high-traffic pathways in your home now. The same is true if you are going to attempt to travel through your brain along low-traffic pathways of non-restriction.
While you know that I always recommend psychotherapeutic support as a foundational element of successful recovery no matter your age, but it becomes increasingly critical to success the older you are and the more you have practiced restriction. There are some well-designed workbooks out there to guide you through self-directed CBT, but we all do better with accountability framing our efforts to practice new behaviors. Any accredited counselor or therapist will generate the external accountability you need to keep going as well as provide you with some much needed cheerleading in the early awkward phases of implementing non-restrictive behaviors.
Most men and women in this age bracket will have been actively on the eating disorder spectrum for at least a decade. In that time, the executive functions of the brain (frontal lobes) have had to spend a lot of time rationalizing and minimizing the cognitive dissonance of knowing that restriction is damaging yet continuing to practice it nonetheless.
In English, when we don't behave in a way that we know is in our best interests we experience a gap, or chasm, between how we like to define ourselves and how we are really behaving. That gap is called cognitive dissonance, or sometimes ego dystonia. It is uncomfortable and in response to it we try to lessen its impact by re-framing the reasons for our actions so that they don't seem so out of character to our sense of self. It is also possible to lessen that dissonance by determining that we have acted "out of character" and that we intend not to continue the behavior because it is not in our best interests. We all reduce cognitive dissonance in both ways for all sorts of behavior anomalies.
However, when stopping a behavior ratchets up anxiety levels (as is the case with the eating disorder spectrum), then we are far more likely to choose to rationalize continuing the behavior (it's not that bad) because the instinctive way to reduce anxiety is to avoid the stimulus that causes it. Way back when or even on repeated occasions, you likely tried to stop restricting. And after a few hours or a few days, you completely melted down. Faced with feeling like a failure, you were forced to apply as much rationalization as you could because you felt trapped in continuing to do something you knew was not in your best interests.
The rationalizations tend to fall into 3 basic categories:
1) 360° denial
There are honestly not too many folks in this age bracket who continue to apply 24/7 360° denial. Living life and developing adult relationships tends to remove that inherent sense of immortality and superiority that mark our teen years. Essentially there are no chinks in the armor of someone practicing 360° denial. Of those on this spectrum who fit this category, they are marked by black and white thinking. They have a vitriolic abhorrence of those who are overweight and they express it often. They expend much energy convincing others that they eat normally and regularly (think along the lines of Leanne Rimes and her endless tweets about "pigging out"). Their family knows it is a no-go zone because past efforts to broach the topic have always resulted in righteous indignation and arguments. Of course, they have no actual success in convincing others of their health and fitness, but they do have reasonable success at convincing themselves for a while. As I mentioned, older patients use this form of rationalization much less than younger patients. However, the exception may be if you have developed late-onset anorexia nervosa. Late-onset anorexia is clinically defined as the first bout of self-administered starvation happening at or after age 25. If you have late-onset anorexia then you may be more prone to using 360° denial until health problems finally catch up with you.
The most common form of rationalization for this 26-52 age bracket is bargaining. You may bargain with yourself and/or your loved ones. You expend some of your cognitive energy (because this is how you really want to see yourself) applying non-restrictive behaviors but reward yourself for having done so by subsequently applying the familiar restrictive behaviors. Unfortunately because the restrictive behaviors become the reward for the bargain of having applied a non-restrictive behavior, this cycle only greatly reinforces the need for rationalizations for the cognitive dissonance you now face. How can a damaging behavior actually be considered a reward? Well by suggesting to yourself that a) the effort you made not to restrict was enormous and really counted and b) the reward of restricting was tiny and really didn't damage anything at all.
Many of you can likely recognize yourself in this category. And you hate how whiny and cajoling you can be with loved ones: "But why are you on my case now? Didn't I eat the pizza with the kids last night and we all had a good time right?"; "Look I promise that I won't go for my run today if it really bothers you that much!"; or "Seriously, I am really not hungry right now, I had a huge lunch -- oh, like that never happens to you?!"
Not only that, the white lies pile up fast when you use this kind of rationalization and it gets hard to keep track as to whether you were supposed to have gone for a run on Tuesday or not, as an example.
Next in line to bargaining is comparisons as a form of rationalization. In fact, when the chinks start to show in the armor of 360° denial, many shift to comparisons as a way to continue avoiding the dissonance they face. This rationalization is so easy to apply in today's world. There is almost always someone skinnier, applying more severe forms of restriction, and even applying more severe forms of rationalization than you do.
Even more sinister is the fact that extreme anxiety about obesity in our society means you can often just use corroboration rather than even a comparison: "The doctor said I am the picture of health,"; "Look, no one is telling me I am too thin!"; "How can I have a problem if I can do (fill in the blank)?" Because 2/3 of all those on this spectrum are not clinically underweight, they can hide it well and the medical experts are much more likely to suggest all manner of chronic conditions rather than identifying that the sub-optimal weight they have is the source of their medical ailments.
In a celebrity-infused culture, where men and women are magically underweight, buff, healthy, fit, wholesome and also still fertile all without any supposed pharmaceutical or medical intervention, comparisons are the toughest of the rationalizations to dislodge.
"If these famous people can all be underweight, muscular, supremely healthy, fit and yet they are telling us they are not on the eating disorder spectrum, then why get on my case?"
If you predominantly use this form of rationalization, then you will first have to work at accepting the image of famous healthy fit people is just that: an image. The amount of fertility treatment used for women too thin to procreate; the use of postpartum cosmetic surgery to create that miraculous post-baby body; and the number of celebrities struggling with eating disorders who hide that it is the source of their osteopenia, their need for dental implants or that it drives their ridiculous dieting cycles, are all carefully excised from the public personas they provide in collusion with the media industry. Occasionally the odd celebrity allows you behind the curtain. When Gwen Stefani was asked about her thinness on her first solo tour she bluntly said: "I am basically starving." Unfortunately, those glimpses are too few and far between.
In the end, whether you use a bit of all the rationalization forms at different times, or you stick with just one or two, you have to accept that you can no longer bridge the gap between who you think you are and how you behave, by making excuses for continuing to behave in a way that is damaging to yourself. So now, to help you on that journey, I'm going to play the Ghost of the Future and show the things that might be if you continue to rationalize rather than tackle the replacement of those restrictive eating behaviors.
Ugly Facts and Statistics to Increase Cognitive Dissonance
A meta-analysis of 900,000 subjects published in the Lancet in 2009 was able to show that those with a BMI of 22 had the lowest overall mortality rates. Interestingly, life expectancy rates drop for those below BMI 22. At BMI 17.5, the study estimated a shortened life expectancy of up to 7 years.
Other studies have already indicated that women with chronic restrictive eating behaviors die about 12 years earlier than non-ED counterparts.
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) and excessive subcutaneous abdominal fat due to long term elevated serum glucocorticoid levels.
Assuming a life expectancy of 78-80, then continuing to practice restricted eating behaviors either intermittently or constantly will result in an early death of anywhere from age 66 to 73. Not only that, from mid-40s onwards you will essentially be an invalid. If you are married/partnered and/or have children still dependent on you at age 40 or so, then the progression of chronic illness you deal with at that point will drain much of the focus and energy from the family. If you are single and live alone, then the process of dealing with your illness alone is very draining on you, as well as your kin, your friends and professional colleagues (to the extent they are involved).
If you have children, then you also must accept the genetic and environmental legacy you are passing onto your children. While Mom and Dad may think they are somehow protecting the children from the chronicity and progression of the eating disorder that either one of them has, the reality is that the children are absorbing all of it.
Studies indicate that the strongest correlate for the presence of family dysfunction and subsequent mental instability and illness for the children when they reach adulthood, is a family secret. If you have not told the children that you are struggling to address being on the eating disorder spectrum, then that qualifies as a family secret.
We all get the genes we get, but how those genes are expressed is environmentally determined. The chance that your children are predisposed to develop eating disorders is very high, but those genes are activated by detrimental environmental inputs (inadvertent comments about body image, weight gain, just living in our image-obsessed world, etc.). You can provide them with protective environmental inputs and one of the most protective will definitely be how you address your own restrictive eating behaviors and your efforts to recover.
One particularly disturbing aspect of this spectrum disorder in adult women is that they inadvertently under-nourish their children. Please note the women involved in these studies loved and adored their children--it happens entirely subconsciously and should not be judged as anything other than yet another marker of how any chronic illness impacts a family in myriad ways. Also keep in mind that women are still predominantly responsible for family nourishment and health, but that does not mean that having a father with restrictive eating behaviors is not going to impact children in very similar ways as when the mother is the one struggling with restricted eating behaviors.
GHOST OF THE FUTURE COME TO WARN YOU
I have just forced more cognitive dissonance on you by pointing out that restrictive eating means you intend to dump more responsibility and emotional strain on family and friends as you get sicker. If you have children, you feel even more uncomfortable right now because you are modeling harmful behaviors that they are going to be genetically predisposed to apply themselves in future without some counter-balancing protective environmental inputs. Don't worry, although it gets even more uncomfortable in this next section in the end it should vastly improve your chances of seeking out the full remission you deserve.
I expect you will be frantically cycling through the usual rationalizations because the anxiety is increasing as, through reading this post, the mirror is being held up to the behaviors and not just the person you believe you really are. If the anxiety has you screaming to the nearest corner of avoidance you can find, then before you leave off of reading any further I would like you to just read the next paragraph before you leave the rest for another time:
No matter what you decide, let your GP know that you do chronically restrict calories, or cycle through restriction and reactive eating cycles, and/or create deficits through compulsive exercise. Your GP needs to know that the oncoming medical issues you are likely to have (especially if you stay on the rationalization path) originate from chronic starvation or cycles of starvation and reactive eating because it will greatly help him or her in avoiding wrong diagnoses. If your GP thinks your eating behaviors are immaterial, then find another GP. I want you well looked after no matter what you decide.
Alright for those of you planning to get through this entire thing from start to finish, let's wade forward into the future of restricted eating behaviors that continue unabated to age 45 or so:
Being a natural weight involves no restriction. Men and women who spend the bulk of their adult lives at their natural optimal weights experience no reduction in metabolic rate until menopause (for women) and around 55 for men. And even then, the reduction is tiny: some 50-100 kcal/day at absolute maximum.
However, an adult life spent restricting creates progressive metabolic decreases through each decade. In fact, in nutritional lore you will often hear experts say that your metabolism slows as you age but this is because much of the data that generate this so-called truism do not separate out those who restrict and those who don't. Basically if you clean up the dirty raw data, then you can see two distinct graph lines appear: 1) a level line representing metabolic rate from age 25-50 something for those who don't restrict and 2) a decreasing slope representing metabolic rates of those who restrict from ages 25-50 something.
It is important to note that daily intake must involve no restriction to avoid metabolic suppression. If you consider a car that takes a corner too fast and crashes into a pole and the pre-impact speed was 120 mph and the post-impact speed is 0 mph, it's pretty laughable to tell you that the average speed of the car was 60 mph. In the case of the accident, it's the pre-impact speed that is of importance. In the case of cycles of restriction and reactive eating, the "pre-impact" speed is actually 0 mph -- in other words the body reduces metabolism because you are starving and the fact that there is subsequent intermittent energy in does not change that pre-impact speed.
Because your metabolic rate has decreased with each passing decade, this has tremendous negative impact when you reach menopause. Women who do not restrict through their adult lives have no metabolic depreciation until menopause. At that point there is a slight reduction in metabolic rate. There is another around age 70 (for both men and women). Women who don't restrict tend to have energy requirements of 2100 kcal/day by their mid-70s.
Women who restrict have had metabolic reductions throughout their adult menstruating years as the body was always trying to adjust to keeping them alive despite inadequate energy intake. By the time they get to menopause, they are often subsisting on 1300-1500 calories a day.
After menopause, these women find that they begin to put on weight at 1300 odd calories a day. This generates tremendous reactive panic. In response, many end up at clinical levels of starvation (under 1000 calories a day) just to try to maintain their emaciated frames.
In addition to sliding into severe starvation, these women also start to have all the physiological damage of years of sub-clinical starvation and cycles of starvation/reactive eating come home to roost. They begin to experience fractures (wrists, ankles and feet usually, although spine and rib are also common). They are in a lot of pain from the fractures and the thinning of the pelvic bones. Their gastrointestinal function is severely impaired. They struggle with chronic constipation, bloating and GI pain. Their mental functions are also severely impaired. The hippocampus is smaller than average due to the stress of starvation and this impacts the memory and retention capabilities -- they often test equivalent to women in their 80s when they are in their 50s. There is some indication that this mental impairment due to starvation leads to early onset dementia as well.
The prescriptions start to mount up to try to address all the symptoms. Of those I have come across in my own practice, most are on at least 6 prescriptions on a daily basis with upwards of 12 not being that unusual.
There are a lot of doctor visits, specialist visits and hospitalizations as well: dealing with fractures, heart arrhythmias, gastrointestinal distress, clinical depression, severe generalized anxiety, liver and kidney dysfunction (sometimes failure), and endless tests and screens monitoring the deterioration of endocrine function, electrolyte balances etc.
From age 50-ish onwards your quality of life will be severely compromised.
If you have ever read A Christmas Carol, then you know the most unpleasant aspect of Ebenezer Scrooge's journey to the future is to discover he is alone and unmourned. But it is also the most compelling reason he finds to change his behavior when he realizes that there is still time to do so.
The toll that chronic restrictive eating behaviors takes on marriages and families is severe. Most spouses are unable to maintain the role of caregiver and divorce is a common occurrence. Because this is anecdotal I cannot say if this is statistically relevant, but of those I have encountered, divorce seems to occur around menopause and not while there are children still in the home.
Sexual relations cease altogether several years before divorce. There are inadequate hormone levels to generate an average sex drive; intercourse is often painful (particularly the case for women); and intimacy is generally anxiety-provoking due to the extreme attention on failing to meet rigid self-assigned concepts of body image.
The adult children are more commonly estranged. Again, this is likely due to the stress of trying to reconcile why a loved-one will not take better care of himself or herself -- self-administered restrictive eating behaviors are particularly nonsensical to those who are not driven by the same compulsion. The frequency of estrangement from family seems to parallel estrangement levels seen with mental disorders such as schizophrenia.
Alienation from other family members (siblings and parents if still alive) is the norm as well. Along with the deterioration of all the personal and intimate relationships, the 50-something patient also finds professional supports start to fray around the edges as well.
Physicians, in particular, lose patience with those who continue to make appointments to address yet another ailment that would be easily rectified by proper nourishment. Some physicians threaten to admit the patient to psychiatric care as a way to either get them off their books or push for some more tangible effort towards recuperation. Unfortunately for the patient, the threat exacerbates anxiety and results in him or her avoiding medical attention and subsequently being under-medicated for mounting health issues. It usually just results in a further deterioration of quality of life.
Most 50-something patients do not die of heart failure (which is the expected outcome of chronic starvation or cyclical starvation/reactive eating); they commit suicide (that is statistical, not anecdotal).
"BUT IF THE COURSES BE DEPARTED FROM, THE ENDS WILL CHANGE?"
Ebenezer Scrooge (C. Dickens, A Christmas Carol).
Here is the bottom line: 1) turn it all around now, 2) continue to push the need for recovery down the list of priorities and hope somehow magically you will be the exception to the above prognosis.
You can reverse any osteoporosis*, damage to hippocampus, endocrine disorders, damage to the kidneys and liver…all of it will heal fully. There will need to be lifelong vigilance to avoid relapse but with a bit of attention to triggers, there can be complete and permanent remission (as there can be with chronic conditions like rheumatoid arthritis or asthma).
*Osteoporosis takes approximately 7 years to reverse completely and either after menopause (women) or after age 50 (men), recovering from restrictive eating behaviors will not include the complete reversal of osteoporosis, but it will halt the progression. If you are closer to menopause than not, then all the more reason to learn and practice non-restricted eating behaviors because what osteoporosis you can reverse now will be extremely beneficial to you in your later years.
However unlike Ebenezer Scrooge's one-night transformation, you will have to practice walking around the low-traffic areas of your mind many, many times before you start to feel the benefits of doing away with rationalizations in favor of behaving in ways that align with who you really want to be. That's the difference with novels and real life -- our most satisfying and rewarding moments in life are usually achieved at the end of years of hard work. You can get there whether you are 26, 32, or 44 or 52, or beyond.