Late onset anorexia nervosa and the role of parental family. Presentation of two cases

Anorexia Nervosa (AN) has traditionally been considered an illness of young individuals and its etiology has been linked with the stress of the transition from childhood to adolescence and adulthood. A recent study reported that 4.6 % of middle aged women were suffering from eating disorder (ED) and an additional 4.8 % displayed subthreshold ED [1]. The literature on late onset EDs is sparse with only a few studies and case reports published in the last decades [2]. However, there are earlier documentations of the appearance of AN in older ages, as shown already back in 1874, in the record of a Lasegue’s patient that was 32 years old at the onset of the disorder [3]. Dally in 1984 [4] described four groups of women that developed ‘‘tardive anorexia’’ related to marriage (in the engagement period, during marriage, within 3 years of pregnancy and during menopause). He considered the first three groups forming a continuum with the adolescent form of anorexia nervosa, characterized of unresolved developmental conflicts, whereas the fourth group was characterized by the loss of will to live, despite the occasional histrionic use of starvation for gain. It has been hypothesized that the perpetuating factors of late life AN include relief from social and domestic responsibilities, control over others and reduced outside involvement [4]. Stressful events prior to the development of ED and comorbid major depression have also been related to late onset AN [2, 4, 5]. It should be noted that some authors report that they did not found any evidence of real late onset AN [6]. It is noteworthy that although the parental’s family role in the development and treatment of AN has been thoroughly investigated [7], the authors that have studied late onset AN have focused more on marriage and the relationship with the husband [4]. The family ties in Greece, as in most Southern European countries, remain strong and expand beyond the core family. It is not uncommon to meet an extended family living in the same block of flats or in great proximity. In these families, the leading role is usually retained by the elder members. Under these circumstances, the issue of autonomy and self-identity in certain occasions remains unresolved even in late age. Can the above conditions contribute to the development of late onset AN? To further discuss this issue we present brief vignettes of two patients. Both patients were treated in a university ED outpatient clinic. They were diagnosed according to DSM-IV TR criteria as suffering from an anorexia nervosa (purging type). Both patients reported fears of gaining weight, distorted body image and low Body Mass Index (BMI) (case 1 lower than 17.5 and case 2 marginally higher than 17.5 but dropped lower than 17.5 after 2 weeks of treatment). The fourth diagnostic criterion could not be utilized as both women were in their menopause. Both women have been extensively investigated, prior to their first appointment in the outpatient clinic, by their physicians (case 2 was also hospitalized) to exclude medical conditions that could cause or contribute to their symptomatology. Except from electrolyte imbalance and gastritis caused by extensive vomiting (case 2) no other medical condition was discovered. F. Gonidakis (&) G. Georgantopoulos G. Konstantakopoulos E. Varsou Eating Disorders Unit, 1st Psychiatric Department, Eginition Hospital, Athens University Medical School, Vas Sofias 74str, 11528 Athens, Greece e-mail: fragoni@yahoo.com